G.S. 58-51-37

§ 58-51-37. Pharmacy of choice.

(a) Repealed by Session Laws 2025-69, s. 1.1, effective October 1, 2025, and applicable to insurance contracts entered into or amended on or after that date.

(b) Definitions. - The following definitions apply in this section:

(1) 340B contract pharmacy. - As defined in G.S. 58-56A-1.

(2) Contract provider. - A pharmacy granted the right to provide prescription drugs and pharmacy services according to the terms of the insurer.

(3) Copayment. - A type of cost-sharing in which an insured is required to pay a specified predetermined amount, which is either fixed or variable, per unit of service that is incurred at the time of service and in which the insurer pays the remainder of the charge for that service.

(4) Health benefit plan. - As defined in G.S. 58-3-167.

(5) Housing unit. - All of the following are considered housing units:

a. A house.

b. An apartment.

c. A mobile home or trailer.

d. A group of rooms or a single room that is occupied, or intended for occupation, as separate living quarters, in which the occupants live separately from any other persons in the building and have direct access from the outside of the building or through a common hall.

(6) Independent pharmacy. - A pharmacy that is part of a group of 10 or fewer pharmacies under common ownership, including a pharmacy that is part of a group of one.

(7) Insured. - An individual covered by a health benefit plan.

(8) Insurer. - As defined in G.S. 58-3-167.

(9) Reserved for future codification purposes.

(10) Pharmacy. - A pharmacy registered with the North Carolina Board of Pharmacy.

(11) Pharmacy desert. - Either of the following areas:

a. An urban community or neighborhood without a pharmacy within a 2-mile radius of any point in the community or neighborhood.

b. A rural community without a pharmacy within a 15-mile radius of any point in the community.

(12) Rural. - An open county or settlement with fewer than 5,000 residents or 2,000 housing units.

(13) Urban. - A densely developed area with at least 5,000 residents or 2,000 housing units.

(b1) Applicability. - This section applies to insurers offering health benefit plans that include prescription drug or pharmacy benefits. This section shall also apply to pharmacy benefits managers in the same way that it applies to insurers with respect to 340B covered entities and 340B contract pharmacies. This section does not apply to any federal program or clinical trial program, hospital, or other health care facility licensed pursuant to Chapter 131E or Chapter 122C of the General Statutes, when dispensing prescription drugs to its patients.

(1) Prohibit or limit an insured who is eligible for reimbursement for pharmacy services from selecting a pharmacy of the insured's choice when the pharmacy has agreed to participate in the health benefit plan according to the terms offered by the insurer.

(2) Deny a pharmacy the opportunity to participate as a contract provider under a health benefit plan if the pharmacy agrees to provide pharmacy services that meet the terms and requirements, including terms of reimbursement, of the insurer under a health benefit plan. If a pharmacy is offered the opportunity to participate as a contract provider, then the pharmacy must participate or no provisions of G.S. 58-51-37 shall apply.

(3) Impose upon an insured any copayment, fee, or condition that is not equally imposed upon all insureds in the same benefit category, class, or copayment level under the health benefit plan when receiving services from a contract provider.

(4) Impose a monetary advantage or penalty under a health benefit plan that would affect an insured's choice of pharmacy, including a higher copayment, a reduction in reimbursement for services, or the promotion of one contract provider over another by these methods. Prohibitions on the imposition of a monetary advantage shall not apply to monetary advantages imposed upon a pharmacy located in a pharmacy desert or a county with a population of fewer than 20,000 residents.

(5) Reduce allowable reimbursement for pharmacy services to an insured because the insured selects a pharmacy of his or her choice, so long as that pharmacy has enrolled with the health benefit plan under the terms offered to all pharmacies in the plan coverage area.

(6) Require an insured, as a condition of payment or reimbursement, to purchase pharmacy products or services, including prescription drugs, exclusively through a mail-order pharmacy.

(d) Use of Agent. - A pharmacy, by or through a pharmacist acting on its behalf as its employee, agent, or owner, may not waive, discount, rebate, or distort a copayment of any insurer or health benefit plan or an insured's coinsurance portion of prescription drug coverage or reimbursement of a prescription drug. If a pharmacy, by or through a pharmacist's action on its behalf as its employee, agent, or owner, provides a pharmacy service to an insured that meets the terms and requirements of the insurer under a health benefit plan, then the pharmacy shall provide its pharmacy services to all individuals covered under that health benefit plan on the same terms and requirements of the insurer. A violation of this subsection is a violation of the Pharmacy Practice Act subjecting the pharmacist as a licensee to disciplinary authority of the North Carolina Board of Pharmacy pursuant to G.S. 90-85.38.

(e) Offer to Participate. - At least 60 days before the effective date of any health benefit plan coverage for prescription drugs that restricts pharmacy participation, the insurer providing the health benefit plan shall provide a written notification and offer to all pharmacies within the geographical coverage area of the health benefit plan the opportunity to participate in the health benefit plan. All pharmacies in the geographical coverage area of the plan shall be eligible to participate under identical reimbursement terms for providing pharmacy services, including prescription drugs. The insurer shall, through reasonable means, on a timely basis, and on regular intervals in order to effectuate the purposes of this section, inform insureds of the names and locations of pharmacies that are participating in the plan as providers of pharmacy services and prescription drugs. Additionally, participating pharmacies shall be entitled to announce their participation to their customers through a means acceptable to the pharmacy and the insurer. The pharmacy notification provisions of this section shall not apply when an individual or group is enrolled, but when the plan enters a particular county of the State.

(f) Rebates and Marketing Incentives. - If rebates or marketing incentives are allowed to pharmacies or other dispensing entities providing pharmaceutical services or benefits under a health benefit plan, these rebates or marketing incentives shall be offered on an equal basis to all pharmacies and other dispensing entities providing services or benefits under the health benefit plan when pharmacy services, including prescription drugs, are purchased in the same volume and under the same terms of payment. Nothing in this section shall prevent a pharmaceutical manufacturer or wholesale distributor of pharmaceutical products from providing special prices, marketing incentives, rebates, or discounts to different purchasers not prohibited by federal and State antitrust laws.

(g) Violations of This Section. - It shall be a violation of this section for any insurer to provide any health benefit plan providing coverage for pharmaceutical services or products to residents of this State that does not conform to the provisions of this section. A violation of this section shall subject the insurer to the sanctions of revocation, suspension, or refusal to renew license in the discretion of the Commissioner pursuant to G.S. 58-3-100. A violation of this section creates a civil cause of action for damages or injunctive relief in favor of any person or pharmacy aggrieved by the violation.

(h) Repealed by Session Laws 2025-69, s. 1.1, effective October 1, 2025, and applicable to insurance contracts entered into or amended on or after that date.

(i) Approval by Commissioner. - The Commissioner shall not approve any health benefit plan providing pharmaceutical services that does not conform to this section.

(j) Provisions to the Contrary Void. - Any provision in a health benefit plan which is executed, delivered, or renewed, or otherwise contracted for in this State that is contrary to any provision of this section shall, to the extent of the conflict, be void.

(k) Repealed by Session Laws 2025-69, s. 1.1, effective October 1, 2025, and applicable to insurance contracts entered into or amended on or after that date.

(l) Certain Lock-In Programs. - An insurer's use of a lock-in program developed pursuant to G.S. 58-51-37.1 or G.S. 108A-68.2 is not a violation of this section. (1993, c. 293, s. 1; 2018-49, s. 3(c); 2018-145, s. 10; 2021-161, s. 4; 2023-134, s. 9E.23(a2); 2025-69, s. 1.1.)