Article 56A.
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Article 56A.
Pharmacy Benefits Management.
§ 58-56A-1. Definitions.
The following definitions apply in this Article:
(1)340B contract pharmacy. - Any pharmacy under contract with a 340B covered entity to dispense drugs on behalf of the 340B covered entity.
(2)340B covered entity. - Any entity defined in 42 U.S.C. § 256b(a)(4)(A), 42 U.S.C. § 256b(a)(4)(C), 42 U.S.C. § 256b(a)(4)(D), 42 U.S.C. § 256b(a)(4)(E), 42 U.S.C. § 256b(a)(4)(I), 42 U.S.C. § 256b(a)(4)(J), 42 U.S.C. § 256b(a)(4)(K), 42 U.S.C. § 256b(a)(4)(N), or 42 U.S.C. § 256b(a)(4)(O).
(3)Claim. - A request from a pharmacy or pharmacist to be reimbursed for the cost of filling or refilling a prescription for a drug or for providing a medical supply or device.
(4)Claims processing service. - The administrative services performed in connection with the processing and adjudicating of claims relating to pharmacist services that include either or both of the following activities:
a. Receiving payments for pharmacist services.
b. Making payments to pharmacists or pharmacies for pharmacist services.
(4b)Reserved for future codification purposes.
(5)Health benefit plan. - As defined in G.S. 58-3-167.
(5a)High-deductible health plan. - As defined under the Internal Revenue Code.
(6)Insured. - An individual covered by a health benefit plan.
(7)Insurer. - As defined in G.S. 58-3-167.
(8)Maximum allowable cost list. - A listing of generic or multiple source drugs used by a pharmacy benefits manager to set the maximum allowable cost on which reimbursement of a pharmacy is made.
(9)Maximum allowable cost price. - The maximum amount that a pharmacy benefits manager will reimburse a pharmacy for the cost of generic or multiple source prescription drugs, medical products, or devices.
(10)Out-of-pocket costs. - With respect to the acquisition of a drug, the amount to be paid by the insured under the plan or coverage, including any cost-sharing, copayment, coinsurance, or deductible.
(11)Pharmacist. - A person licensed to practice pharmacy under Article 4A of Chapter 90 of the General Statutes.
(12)Pharmacist services. - Products, goods, or services provided as a part of the practice of pharmacy.
(13)Pharmacy. - As defined in G.S. 90-85.3(q).
(14)Pharmacy benefits manager. - An entity who contracts with a pharmacy on behalf of an insurer or third-party administrator to administer or manage prescription drug benefits to perform any of the following functions:
a. Negotiating rebates with manufacturers for drugs paid for or procured as described in this Article.
b. Processing claims for prescription drugs or medical supplies or providing retail network management for pharmacies or pharmacists.
c. Paying pharmacies or pharmacists for prescription drugs or medical supplies.
(15)Pharmacy benefits manager affiliate. - A pharmacy or pharmacist that directly or indirectly, through one or more intermediaries, owns or controls or is owned or controlled by a pharmacy benefits manager.
(16)Pharmacy service administrative organization (PSAO). - An organization that assists community pharmacies and pharmacy benefits managers or third-party payors in achieving administrative efficiencies, including contracting and payment efficiencies.
(16a)Section 223. - Section 223 of the Internal Revenue Code or its equivalent.
(16b)Specialty drug. - Any of the following prescription medications:
a. A medication that is subject to restricted distribution by the United States Food and Drug Administration.
b. A medication used to treat complex or chronic conditions that requires special handling, provider coordination, or patient education.
c. A medication classified as a specialty drug as determined by a health benefit plan.
(16c)Specialty pharmacy. - A pharmacy accredited as a specialty pharmacy by a nationally recognized, independent accrediting organization that evaluates a pharmacy's compliance with quality, safety, and service standards for handling, dispensing, and managing specialty drugs. The accreditation may be issued by the Utilization Review Accreditation Commission (URAC), the Accreditation Commission for Health Care (ACHC), the National Association of Boards of Pharmacy (NABP), the Joint Commission, or their successors.
(17)Third-party administrator. - As defined in G.S. 58-56-2. (2014-120, s. 20(a); 2017-116, s. 1; 2021-161, s. 1(b); 2025-69, s. 3.1(a).)