HB 163 would significantly expand North Carolina’s regulation of pharmacy benefits managers (PBMs) and related health plan pharmacy practices. The bill prohibits spread pricing, defines and limits “concessions” such as rebates and fees, and bars PBMs from imposing a range of fees, retroactive adjustments, and reimbursement practices that would pay pharmacies below the national average drug acquisition cost plus a dispensing fee. It also requires PBMs to allow credentialed specialty pharmacies to participate in networks on equal terms, prevents PBMs from steering claims to discount-card or other non-insurance platforms, and requires PBMs to report detailed concession and acquisition-cost data to the Commissioner of Insurance on a quarterly basis beginning in 2026.
The bill also revises North Carolina’s “pharmacy of choice” protections to clarify that insureds may select any participating pharmacy, that insurers cannot impose unequal copayments or penalties based on pharmacy choice, and that mail-order cannot be required as a condition of coverage. It updates cost-sharing rules so out-of-pocket calculations for certain prescriptions are based on net price after concessions rather than retail price, and it makes technical changes to align definitions and applicability provisions, including expressly excluding local government self-funded plans from the definition of “health benefit plan.”
A third major component strengthens pharmacy audit protections. It limits PBM audits of retail pharmacies to once per calendar quarter and caps the number of prescriptions that may be reviewed, requires advance notice and documentation before recoupments, and makes these audit protections enforceable against PBMs, insurers, and third-party administrators by the Commissioner of Insurance and the Board of Pharmacy. The bill also preserves exceptions for Medicaid fraud, insurance fraud, and other criminal fraud investigations.
Overall, the bill appears to have been framed as a consumer- and pharmacy-protection measure, with no recorded committee transcript or vote data in the provided materials to indicate formal opposition or support. The structure and breadth of the bill suggest a policy goal of increasing transparency, limiting PBM leverage over pharmacies, and reducing patient cost distortions. Because it touches reimbursement, network participation, audits, and reporting, it would materially affect PBMs, insurers, pharmacies, pharmacists, and insured consumers across the state.
HB 163 would amend multiple chapters of the North Carolina General Statutes, primarily Chapter 58 (insurance and PBMs) and Chapter 90 (pharmacy audits). It would create new PBM conduct restrictions, require new reporting to the Department of Insurance, expand pharmacy network and pharmacy-of-choice rights, alter cost-sharing calculations, and tighten audit and recoupment procedures. It also clarifies that certain local government self-funded plans are not covered by the state’s health benefit plan provisions, which narrows the reach of some insurance mandates.
The available context shows no committee transcript and no recorded votes, so there is no direct evidence of debate tone in the supplied materials. Based on the bill’s content, the measure is oriented toward stronger consumer protections and pharmacy protections, and it appears designed to address concerns about PBM pricing practices, network restrictions, and audit recoupments. The bill’s repeated committee substitute favorable actions suggest it advanced through committee review in a generally favorable posture.
The most likely points of contention are the bill’s restrictions on PBM revenue practices, especially the ban on spread pricing, limits on rebates and concessions, and the requirement to reimburse pharmacies at or above national average drug acquisition cost plus a dispensing fee. PBMs and insurers could also object to the reporting requirements, limits on audit scope, and restrictions on using policy documents to alter contract terms. Another possible area of dispute is the bill’s expansion of pharmacy-of-choice rights and specialty pharmacy network access, which may be viewed as limiting plan design flexibility. The exclusion of local government self-funded plans may also be notable for affected public employers and plan administrators.