North Carolina General Statutes 97-26.2. Reimbursement for prescription drugs, prescribed over-the-counter drugs, and professional pharmaceutical services
(a) The reimbursement amount for prescription drugs, prescribed over-the-counter drugs, and professional pharmaceutical services shall be limited to the lesser of ninety-five percent (95%) of the average wholesale price (AWP) of the product, calculated on a per unit basis, as of the date of dispensing or the reimbursement amount provided for in an agreement between the dispensing health care provider and the payor employer or workers’ compensation insurance carrier.
(b) All of the following shall apply to the reimbursement for prescription drugs and professional pharmaceutical services:
(1) A health care provider seeking reimbursement for health care provider-dispensed prescription drugs, prescribed over-the-counter drugs, and pharmaceutical services shall include the original manufacturer’s National Drug Code (NDC) number, as assigned by the United States Food and Drug Administration, on any billing documents or invoices issued.
Terms Used In North Carolina General Statutes 97-26.2
- compensation: means the money allowance payable to an employee or to his dependents as provided for in this Article, and includes funeral benefits provided herein. See North Carolina General Statutes 97-2
- employee: means every person engaged in an employment under any appointment or contract of hire or apprenticeship, express or implied, oral or written, including aliens, and also minors, whether lawfully or unlawfully employed, but excluding persons whose employment is both casual and not in the course of the trade, business, profession, or occupation of his employer, and as relating to those so employed by the State, the term "employee" shall include all officers and employees of the State, including such as are elected by the people, or by the General Assembly, or appointed by the Governor to serve on a per diem, part-time or fee basis, either with or without the confirmation of the Senate; as relating to municipal corporations and political subdivisions of the State, the term "employee" shall include all officers and employees thereof, including such as are elected by the people. See North Carolina General Statutes 97-2
- employer: means the State and all political subdivisions thereof, all public and quasi-public corporations therein, every person carrying on any employment, and the legal representative of a deceased person or the receiver or trustee of any person. See North Carolina General Statutes 97-2
- 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
- health care provider: means physician, hospital, pharmacy, chiropractor, nurse, dentist, podiatrist, physical therapist, rehabilitation specialist, psychologist, and any other person providing medical care pursuant to this Article. See North Carolina General Statutes 97-2
- United States: shall be construed to include the said district and territories and all dependencies. See North Carolina General Statutes 12-3
(2) In no event may a health care provider receive reimbursement in excess of ninety-five percent (95%) of the AWP of the drugs dispensed by a health care provider, as determined by reference to the original manufacturer’s NDC number.
(3) A repackaged NDC number may not be individually used on any billing documents or invoices issued and will not be considered the original manufacturer’s NDC number. A repackaged NDC number may only appear in conjunction with the manufacturer’s NDC number. If a health care provider seeking reimbursement for drugs dispensed by a health care provider does not include the original manufacturer’s NDC number on any billing documents or invoices issued, reimbursement shall be limited to one hundred percent (100%) of the AWP of the least expensive clinically equivalent drug, calculated on a per unit basis.
(4) No outpatient health care provider, other than a licensed pharmacy, may receive reimbursement for a Schedule II controlled substance, as defined in N.C. Gen. Stat. § 90-90, a Schedule III controlled substance, as defined in N.C. Gen. Stat. § 90-91, a Schedule IV controlled substance, as defined in N.C. Gen. Stat. § 90-92, or a Schedule V controlled substance, as defined in N.C. Gen. Stat. § 90-93, dispensed in excess of an initial five-day supply, commencing upon the employee‘s initial treatment following injury. Reimbursement under this subdivision shall be made for the five-day supply at the rates provided in this section.
(5) For purposes of this section, the term “clinically equivalent” means a drug has chemical equivalents which, when administered in the same amounts, will provide essentially the same therapeutic effect as measured by the control of a symptom or disease. (2014-100, s. 15.16A(a); 2015-241, s. 15.13B(a).)