§97-26.2. Reimbursement for prescription drugs and professional pharmaceutical services

(a)        The reimbursement for prescription drugs and professional pharmaceutical services shall be limited to 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.

(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 drugs dispensed by a physician shall include the original manufacturer's National Drug Code (NDC) number, as assigned by the United States Food and Drug Administration, on the bills and reports required by this section.

(2)        In no event may a physician receive reimbursement in excess of ninety-five percent (95%) of the AWP of the drugs dispensed by a physician, as determined by reference to the original manufacturer's NDC number.

(3)        A repackaged NDC number may not be used and will not be considered the original manufacturer's NDC number. If a health care provider seeking reimbursement for drugs dispensed by a physician does not include the original manufacturer's NDC number on the bills and reports required by this section, 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 provider, other than a licensed pharmacy, may receive reimbursement for a Schedule II controlled substance, as defined in G.S. 90-90, or a Schedule III controlled substance, as defined in G.S. 90-91, 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).)