§ 58-51-37. Pharmacy of choice.
§58‑51‑37. Pharmacy of choice.
(a) This section shallapply to all health benefit plans providing pharmaceutical services benefits,including prescription drugs, to any resident of North Carolina. This sectionshall also apply to insurance companies and health maintenance organizationsthat provide or administer coverages and benefits for prescription drugs. Thissection shall not apply to any entity that has its own facility, employs orcontracts with physicians, pharmacists, nurses, and other health carepersonnel, and that dispenses prescription drugs from its own pharmacy to itsemployees and to enrollees of its health benefit plan; provided, however, thissection shall apply to an entity otherwise excluded that contracts with anoutside pharmacy or group of pharmacies to provide prescription drugs andservices. This section shall not apply to any federal program, clinical trialprogram, hospital or other health care facility licensed pursuant to Chapter131E or Chapter 122C of the General Statutes, when dispensing prescriptiondrugs to its patients.
(b) As used in thissection:
(1) "Copayment"means a type of cost sharing whereby insured or covered persons pay a specifiedpredetermined amount per unit of service with their insurer paying the remainderof the charge. The copayment is incurred at the time the service is used. Thecopayment may be a fixed or variable amount.
(2) "Contractprovider" means a pharmacy granted the right to provide prescription drugsand pharmacy services according to the terms of the insurer.
(3) "Health benefitplan" is as that term is defined in G.S. 58‑50‑110(11).
(4) "Insurer"means any entity that provides or offers a health benefit plan.
(5) "Pharmacy"means a pharmacy registered with the North Carolina Board of Pharmacy.
(c) The terms of ahealth benefit plan shall not:
(1) Prohibit or limit aresident of this State, who is eligible for reimbursement for pharmacy servicesas a participant or beneficiary of a health benefit plan, from selecting apharmacy of his or her choice when the pharmacy has agreed to participate inthe health benefit plan according to the terms offered by the insurer;
(2) Deny a pharmacy theopportunity to participate as a contract provider under a health benefit planif the pharmacy agrees to provide pharmacy services that meet the terms andrequirements, including terms of reimbursement, of the insurer under a healthbenefit plan, provided that if the pharmacy is offered the opportunity toparticipate, it must participate or no provisions of G.S. 58‑51‑37shall apply;
(3) Impose upon abeneficiary of pharmacy services under a health benefit plan any copayment,fee, or condition that is not equally imposed upon all beneficiaries in thesame benefit category, class, or copayment level under the health benefit planwhen receiving services from a contract provider;
(4) Impose a monetaryadvantage or penalty under a health benefit plan that would affect abeneficiary's choice of pharmacy. Monetary advantage or penalty includeshigher copayment, a reduction in reimbursement for services, or promotion ofone participating pharmacy over another by these methods.
(5) Reduce allowablereimbursement for pharmacy services to a beneficiary under a health benefitplan because the beneficiary selects a pharmacy of his or her choice, so longas that pharmacy has enrolled with the health benefit plan under the termsoffered to all pharmacies in the plan coverage area; or
(6) Require abeneficiary, as a condition of payment or reimbursement, to purchase pharmacyservices, including prescription drugs, exclusively through a mail‑orderpharmacy.
(d) A pharmacy, by orthrough a pharmacist acting on its behalf as its employee, agent, or owner, maynot waive, discount, rebate, or distort a copayment of any insurer, policy, orplan, or a beneficiary's coinsurance portion of a prescription drug coverage orreimbursement and if a pharmacy, by or through a pharmacist's acting on itsbehalf as its employee, agent or owner, provides a pharmacy service to anenrollee of a health benefit plan that meets the terms and requirements of theinsurer under a health benefit plan, the pharmacy shall provide its pharmacyservices to all enrollees of that health benefit plan on the same terms andrequirements of the insurer. A violation of this subsection shall be aviolation of the Pharmacy Practice Act subjecting the pharmacist as a licenseeto disciplinary authority of the North Carolina Board of Pharmacy pursuant toG.S. 90‑85.38.
(e) At least 60 daysbefore the effective date of any health benefit plan providing reimbursement toNorth Carolina residents for prescription drugs, which restricts pharmacyparticipation, the entity providing the health benefit plan shall notify, inwriting, all pharmacies within the geographical coverage area of the healthbenefit plan, and offer to the pharmacies the opportunity to participate in thehealth benefit plan. All pharmacies in the geographical coverage area of theplan shall be eligible to participate under identical reimbursement terms forproviding pharmacy services, including prescription drugs. The entityproviding the health benefit plan shall, through reasonable means, on a timelybasis, and on regular intervals in order to effectuate the purposes of thissection, inform the beneficiaries of the plan of the names and locations ofpharmacies that are participating in the plan as providers of pharmacy servicesand prescription drugs. Additionally, participating pharmacies shall beentitled to announce their participation to their customers through a meansacceptable to the pharmacy and the entity providing the health benefit plans. The pharmacy notification provisions of this section shall not apply when anindividual or group is enrolled, but when the plan enters a particular countyof the State.
(f) If rebates ormarketing incentives are allowed to pharmacies or other dispensing entitiesproviding services or benefits under a health benefit plan, these rebates ormarketing incentives shall be offered on an equal basis to all pharmacies and otherdispensing entities providing services or benefits under a health benefit planwhen pharmacy services, including prescription drugs, are purchased in the samevolume and under the same terms of payment. Nothing in this section shallprevent a pharmaceutical manufacturer or wholesale distributor ofpharmaceutical products from providing special prices, marketing incentives,rebates, or discounts to different purchasers not prohibited by federal andState antitrust laws.
(g) Any entity orinsurer providing a health benefit plan is subject to G.S. 58‑2‑70. A violation of this section shall subject the entity providing a health benefitplan to the sanctions of revocation, suspension, or refusal to renew license inthe discretion of the Commissioner pursuant to G.S. 58‑3‑100.
(h) A violation of thissection creates a civil cause of action for damages or injunctive relief infavor of any person or pharmacy aggrieved by the violation.
(i) The Commissionershall not approve any health benefit plan providing pharmaceutical serviceswhich does not conform to this section.
(j) Any provision in ahealth benefit plan which is executed, delivered, or renewed, or otherwisecontracted for in this State that is contrary to any provision of this sectionshall, to the extent of the conflict, be void.
(k) It shall be aviolation of this section for any insurer or any person to provide any healthbenefit plan providing for pharmaceutical services to residents of this Statethat does not conform to the provisions of this section. (1993,c. 293, s. 1.)