HB 820 — Prescription Eye Drop Early Refill Coverage (North Carolina, 2025)
Purpose
- Require health insurers that cover prescription eye drops to allow early refills in defined circumstances so patients are not denied needed medications solely because a standard refill-interval has not elapsed.
Key provisions
- New statute (G.S. 58‑3‑266) requires every health benefit plan offered by an insurer in North Carolina that covers prescription eye drops to permit a refill request to be covered if both conditions below are met:
1. For a 30‑day supply, the patient requests the refill after either:
- the passage of an amount of time after which the patient should have used 70% of the dosage units (based on provider instructions), or
- 21 days after the original prescription date or 21 days after the most recent refill distribution date; and
2. The requested refill would not exceed any total number of refills the prescribing health care provider authorized on the original prescription.
- The statute is limited to prescription eye drops (i.e., ophthalmic medications) and does not override the prescriber’s refill limits.
Applicability / who is affected
- Insurers and health benefit plans that provide coverage for prescription eye drops in North Carolina.
- Patients who use prescription eye drops (including those with chronic eye conditions such as glaucoma or severe dry eye).
- Prescribing clinicians and pharmacists (procedures for refill authorization and claims processing).
- The State Health Plan is explicitly included — G.S. 135‑48.51 is amended to incorporate this requirement.
Timing / effective dates
- The early‑refill coverage provision (Section 1(a)) becomes effective October 1, 2025 and applies to insurance contracts issued, renewed, or amended on or after that date.
- The amendment incorporating the provision into the State Health Plan (Section 1(b)) applies as of the start of the next plan year following the October 1, 2025 date.
- Appropriation (see below) becomes effective July 1, 2025; the act otherwise takes effect when it becomes law.
Fiscal impact
- The bill includes an appropriation: $100,000 in recurring General Fund monies each year of the 2025–2027 biennium to the Department of State Treasurer to cover costs to the State Health Plan arising from providing the new coverage.
- For private insurers, allowing certain early refills may marginally increase pharmacy spending and administrative processing of prior authorizations/refills, but the bill limits exposure by capping refills at the prescriber’s authorized total and by applying defined timing thresholds.
Procedural status and sponsors
- Introduced in the 2025 North Carolina legislative session by Representative Reeder (primary sponsors also include Representatives Campbell, Rhyne, and Crawford).
- Referred to relevant committees (Insurance; Appropriations; others per chamber rules) for review. (Check the NC General Assembly site for current status/amendments.)
Notes / limitations
- The rule applies only to prescription eye drops and only when the two statutory conditions are met.
- The refill permissibility is bounded by the prescriber’s indicated number of refills; it does not require insurers to authorize refills beyond the prescriber’s direction.
- Implementation for existing contracts depends on issuance/renewal/amendment dates, per the effective‑date language.
