AN ACT to expand access to treatment for opioid overdose and opioid use disorder by updating health benefit plan coverage of, and reimbursement for, overdose and substance use disorder medications and to make technical and conforming changes to update the general statutes that relate TO mental health coverage under health benefit plans.

The General Assembly of North Carolina enacts:

part i. create parity for coverage under a health benefit plan applicable to pharmacies and pharmacists

REQUIRE CERTAIN PHARMACY SERVICES TO BE COVERED UNDER A HEALTH BENEFIT PLAN

SECTION 1.1.(a)  Article 3 of Chapter 58 of the General Statutes is amended by adding a new section to read:

§ 58‑3‑241.  Healthcare services provided by pharmacists.

(a)        The following definitions apply in this section:

(1)        Healthcare services. – Any of the following health or medical procedures or services rendered by a healthcare provider:

a.         Testing, assessment, and management of a health condition, illness, injury, or disease. This includes testing, diagnosis, or treatment rendered by a pharmacist acting within the pharmacist's scope of practice.

b.         Dispensing of drugs, medical devices, medical appliances, or medical goods for the treatment of a health condition, illness, injury, or disease.

c.         Administration of a vaccine or medication, including long‑term injectables such as buprenorphine.

(2)        Pharmacist. – An individual licensed to practice pharmacy under Article 4A of Chapter 90 of the General Statutes or the relevant laws of another state.

(b)        A health benefit plan offered by an insurer in this State shall cover healthcare services provided by a pharmacist if all of the following conditions are met:

(1)        The service or procedure was performed within the pharmacist's licensed lawful scope of practice.

(2)        The health benefit plan would have covered the service if the service or procedure had been performed by another healthcare provider.

(c)        The participation of a pharmacy in a drug benefit provider network of a health benefit plan shall not satisfy any requirement that insurers offering health benefit plans include pharmacists in medical benefit provider networks.

SECTION 1.1.(b)  This section is effective October 1, 2025, and applies to insurance contracts issued, amended, or renewed on or after that date.

ACCEPT HEALTHCARE FACILITY CREDENTIALING FOR PHARMACISTS EMPLOYED BY THE FACILITY

SECTION 1.2.(a)  G.S. 58‑3‑230 is amended by adding a new subsection to read:

(d)      Insurers that delegate credentialing agreements or requirements for pharmacists licensed under Article 4A of Chapter 90 of the General Statutes or the relevant laws of another state to a contracted healthcare facility shall accept the credentialing for all pharmacists employed by, or contracted with, those healthcare facilities.

SECTION 1.2.(b)  This section is effective October 1, 2025, and applies to insurance contracts issued, amended, or renewed on or after that date.

PART II. ENHANCE COVERAGE OF PRESCRIPTION DRUGS FOR OPIOID DISORDER AND OPIOID OVERDOSE UNDER HEALTH BENEFIT PLANS

SECTION 2.1.  G.S. 58‑3‑220 is amended by adding a new subsection to read:

(k)      Select Prescription Drugs. – Insurers offering a health benefit plan shall provide coverage of all prescription drugs approved by the United States Food and Drug Administration for the treatment of opioid disorder and opioid overdose. If an insurer maintains one or more closed formularies, then all prescription drugs requiring coverage under this section shall be included on those formularies. The following shall apply to prescription drugs for which coverage is required under this subsection:

(1)        The prescription drug shall not be subject to prior authorization as a condition of coverage.

(2)        Pharmacies dispensing the prescription drug shall be reimbursed at the most recent National Average Drug Acquisition Cost price plus a dispensing fee. If the prescription drug dispensed is not available on the most recent National Average Drug Acquisition Cost price list, then the most recent Wholesale Acquisition Cost price plus a dispensing fee shall be used to reimburse pharmacies for dispensing the prescription drug.

SECTION 2.2.  This Part is effective October 1, 2025, and applies to insurance contracts issued, amended, or renewed on or after that date.

PART Iii. CONFORM TO FEDERAL LAW AND MAKE OTHER TECHNICAL CHANGES TO UPDATE THE GENERAL STATUTES THAT RELATE TO MENTAL HEALTH COVERAGE UNDER HEALTH BENEFIT PLANS

SECTION 3.1.(a)  Subsections (b), (c), (d), and (j) of G.S. 58‑3‑220 are repealed.

SECTION 3.1.(b)  Subsection (h) of G.S. 58‑3‑220 is recodified as subsection (a1) of G.S. 58‑3‑220.

SECTION 3.2.  G.S. 58‑3‑220, as amended by Part II and Section 3.1 of this act, reads as rewritten:

§ 58‑3‑220.  Mental illness health benefits coverage.

(a)        Mental Health Equity Requirement. – Except as provided in subsection (b), an insurer shall provide in each group health benefit plan benefits for All health benefit plans shall provide coverage for the necessary care and treatment of mental illnesses health conditions that are no less favorable than benefits for the necessary care and treatment of physical illness generally, including application of the same limits. For purposes of this subsection, mental illnesses are as diagnosed and defined in the Diagnostic and Statistical Manual of Mental Disorders, DSM‑5, or a subsequent edition published by the American Psychiatric Association, except those mental disorders coded in the DSM‑5 or subsequent edition as autism spectrum disorder (299.00), substance‑related disorders (291.0 through 292.2 and 303.0 through 305.9), those coded as sexual dysfunctions not due to organic disease (302.70 through 302.79), and those coded as V codes. For purposes of this subsection, limits includes deductibles, coinsurance factors, co‑payments, maximum out‑of‑pocket limits, annual and lifetime dollar limits, and any other dollar limits or fees for covered services.health conditions.

(a1)      Definitions. – As used The following definitions apply in this section:

(1)        Health benefit plan has the same meaning as Health benefit plan. – As defined in G.S. 58‑3‑167.

(2)        Insurer has the same meaning as Insurer. – As defined in G.S. 58‑3‑167.

(3)        Medical necessity. – As defined in G.S. 58‑50‑61.

(4)        Mental illness has the same meaning as in G.S. 122C‑3(21), with a Mental health condition. – A mental disorder defined in the Diagnostic and Statistical Manual of Mental Disorders, DSM‑5, or subsequent editions published by the American Psychiatric Association, except this term does not include those mental disorders coded in the DSM‑5 or subsequent editions as autism spectrum disorder (299.00), substance‑related disorders (291.0 through 292.9 and 303.0 through 305.9), those coded as sexual dysfunctions not due to organic disease (302.70 through 302.79), and those coded as V codes.

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(g)        Utilization Review. – Nothing in this section prevents an insurer from applying utilization review criteria to determine medical necessity as defined in G.S. 58‑50‑61 as long as it does so in accordance with all requirements for utilization review programs and medical necessity determinations specified in that section, including the offering of an insurer appeal process and, where applicable, health benefit plan external review as provided for in Part 4 of Article 50 of Chapter 58 of the General Statutes.in accordance with G.S. 58‑50‑61.

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(i)         Notwithstanding any other provisions of this section, a group health benefit plan that covers both medical and surgical benefits and mental health benefits shall, with respect to the mental health benefits, comply with all Federal Law Applies. – All applicable standards of Subtitle B of Title V of Public Law 110‑343, known as the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, and the applicable regulations, as amended.amended, and other relevant federal law shall apply to health benefit plans.

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SECTION 3.3.  The Revisor of Statutes shall replace the phrase chemical dependency with the phrase substance use disorder in all of the following statutes:

(1)        G.S. 58‑51‑16(a).

(2)        G.S. 58‑51‑40(a).

(3)        G.S. 58‑51‑55(b).

(4)        G.S. 58‑65‑90(b).

(5)        G.S. 58‑67‑75(b).

SECTION 3.4.  All of the following are repealed:

(1)        G.S. 58‑51‑50.

(2)        Subdivision (a)(2) and subsection (c) of G.S. 58‑51‑55.

(3)        G.S. 58‑65‑75.

(4)        Subdivision (a)(2) and subsection (c) of G.S. 58‑65‑90.

(5)        G.S. 58‑67‑70.

(6)        Subdivision (a)(2) and subsection (c) of G.S. 58‑67‑75.

SECTION 3.5.  G.S. 58‑3‑192(a)(2) reads as rewritten:

(2)      Autism spectrum disorder. – As defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the most recent edition of the International Statistical Classification of Diseases and Related Health Problems. Autism spectrum disorder is not considered a mental illness health condition, as defined in G.S. 58‑3‑220, 58‑51‑55, or a mental illness, as defined in G.S. 58‑51‑55, 58‑65‑90, or 58‑67‑75.

SECTION 3.6.(a)  G.S. 58‑56‑26 is amended by adding a new subsection to read:

(e)      Notwithstanding any provision of this Article to the contrary, all requirements relating to the coverage of prescription drugs and pharmacy services under this Chapter that apply to health benefit plans are applicable to a third‑party administrator in the same way they are applicable to an insurer.

SECTION 3.6.(b)  Article 56A of Chapter 58 of the General Statutes is amended by adding a new section to read:

§ 58‑56A‑55.  Health benefit plan requirements applicable.

All requirements relating to the coverage of prescription drugs and pharmacy services under this Chapter that apply to health benefit plans are applicable to a pharmacy benefits manager in the same way they are applicable to an insurer.

SECTION 3.7.  This Part is effective when it becomes law and applies to insurance contracts issued, amended, or renewed on or after that date.

part iv. Effective date

SECTION 4.1.  Except as otherwise provided, this act is effective when it becomes law.