PUBLISHED

N.C.G.S. § 97-26.2

Reimbursement for prescription drugs, prescribed over-the-counter drugs, and professional pharmaceutical services.

Effective date: 2026-08-08
Last verified: 2026-08-09
Source: official source
Revision history: view all versions

(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. (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 G.S. 90-90, a Schedule III controlled substance, as defined in G.S. 90-91, a Schedule IV controlled substance, as defined in G.S. 90-92, or a Schedule V controlled substance, as defined in G.S. 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).)