(a) A pharmacy benefits manager may only charge fees or otherwise hold a pharmacy responsible for a fee relating to the adjudication of a claim if the fee is reported on the remittance advice of the adjudicated claim or is set out in contract between the pharmacy benefits manager and the pharmacy. No fee or adjustment for the receipt and processing of a claim, or otherwise related to the adjudication of a claim, shall be charged without a justification on the remittance advice or as set out in contract and agreed upon by the pharmacy or pharmacist for each adjustment or fee. This section shall not apply with respect to claims under an employee benefit plan under the Employee Retirement Income Security Act of 1974 or Medicare Part D.

(b) Nothing in this Article shall abridge the right of a pharmacist to refuse to fill or refill a prescription if the pharmacist believes it would be harmful to the patient or is not in the patient’s best interest, or if there is a question to the validity of the prescription.

(c) A pharmacy or pharmacist shall not be prohibited by a pharmacy benefits manager from dispensing any prescription drug, including specialty drugs dispensed by a credentialed and accredited pharmacy, allowed to be dispensed under a license to practice pharmacy under Article 4A of Chapter 90 of the N.C. Gen. Stat..

(d) A pharmacy benefits manager shall not penalize or retaliate against a pharmacist or pharmacy for exercising rights provided under this Article. This subsection does not apply to breach of contract between a pharmacy and a pharmacy benefits manager.

(e) A claim for pharmacist services may not be retroactively denied or reduced after adjudication of the claim unless any of the following apply:

(1) The original claim was submitted fraudulently.

Terms Used In North Carolina General Statutes 58-56A-4

  • Contract: A legal written agreement that becomes binding when signed.
  • following: when used by way of reference to any section of a statute, shall be construed to mean the section next preceding or next following that in which such reference is made; unless when some other section is expressly designated in such reference. See North Carolina General Statutes 12-3

(2) The original claim payment was incorrect because the pharmacy or pharmacist had already been paid for the pharmacist services.

(3) The pharmacist services were not rendered by the pharmacy or pharmacist.

(4) The adjustments were agreed to by the pharmacy or pharmacist.

(5) The adjustments were part of an attempt to limit overpayment recovery efforts by a pharmacy benefits manager.

(f) Nothing in this section shall be construed to limit overpayment recovery efforts by a pharmacy benefits manager. (2017-116, s. 2; 2021-161, s. 1(b).)

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