CurrentBlue Cross Blue Shield - North CarolinaPolicy N/A

Pricing Development and Maintenance Policy for Drugs - Outpatient Services

Defines how Blue Cross and Blue Shield of North Carolina calculates contractual allowance fees for outpatient drug services (specialty pharmacy and other drug coding scenarios) and who is affected (in-network providers under the Network Participation Agreement).

Policy Summary

PayerBlue Cross Blue Shield - North Carolina

PolicyPricing Development and Maintenance Policy for Drugs - Outpatient Services

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionContact local Network Management to obtain the fee for any drug service code and ensure documentation is available for potential audit.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

quarterlysource update frequency

118% ASP / 90% AWPexample Default Rate bases

hierarchicalrate approach

lesser of chargepayment rule

Reimbursement Determination

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Reimbursement criteria for outpatient drug services

Reimbursement for outpatient drug services (including specialty pharmacy drugs, new/unlisted codes, and miscellaneous codes) is determined by a hierarchy of external pricing sources, application of Default Rates when a specific fee is not available, and contract terms; payment is subject to benefit coverage and claim receipt timing.

Payments and pricing follow the Network Participation Agreement and this Pricing Policy.

External source pricing and updates occur quarterly; updates apply to dates of service on or after the source pricing effective date but only for claims received after Blue Cross NC's implementation date (no retroactive pricing for claims received prior to implementation).

ALL of the following

Hierarchy (apply first available)
- % of 100% Average Sales Price (ASP)
- If ASP does not contain a price for the applicable code: % of Average Wholesale Price (AWP)
- If neither ASP nor AWP provides a price: % of your Reasonable Charge (Blue Cross NC will not allow more than the specified % of Reasonable Charge)

ALL of the following

Any new drug added mid-term that is not yet listed will be assigned the Default Rate per the hierarchy until listed on the Specialty Pharmacy Drug list.
The Default Rate is calculated using the Base Rate% (example statewide: 118% ASP / 90% AWP) and a negotiated multiplier; the percent may vary by drug and is provided in the Network Participation Agreement.
Any AWP‑priced drug that later receives an ASP price mid‑term will be moved to the ASP Default Rate.

ALL of the following

Drugs filed under miscellaneous or unlisted codes will be reimbursed at the percentage of Reasonable Charge indicated in the Network Participation Agreement; Blue Cross NC may price such services using the National Drug Code (NDC).
If a more specific CPT or HCPCS code exists but a miscellaneous/unlisted code is filed, Blue Cross NC will assign the fee for the more specific code to determine reimbursement.

ALL of the following

Blue Cross NC reimburses the lesser of the provider's charge or the applicable fee in accordance with the contract and this Pricing Policy.
Determination of a code‑specific fee does not guarantee benefit coverage or payment; nothing in this Pricing Policy obligates Blue Cross NC to pay for services not covered under the member's benefit plan.

ALL of the following

Blue Cross NC reserves the right to audit and inspect records related to services and supplies provided to members pursuant to the Network Participation Agreement, at no cost to Blue Cross NC.
If an external pricing source referenced in this policy changes, references will be deemed to refer to the superseding source.

Operational note: Providers should contact local Network Management to obtain the fee for any Drug Service code determined by ASP, AWP or WAC criteria and to confirm contract‑specific percent amounts and multipliers.

Actions for Providers and Network Management

Documentation Required

Obtain fee and maintain documentation per Network Management guidance

Contact your local Network Management office to obtain the fee applicable to any Drug Service code and follow contractual documentation and audit requirements; Blue Cross NC reimburses the lesser of your charge or the applicable fee and reserves the right to audit and inspect records under the Network Participation Agreement.

Obtain fee for any Drug Service code from local Network Management.
Follow documentation and record-keeping per the Network Participation Agreement to support billing and allow audits.
Reimbursement will be the lesser of provider charge or applicable fee; fee determination does not guarantee payment.

Key Definitions

Default Rate — application and calculation

When appliedDefault Rate is applied when a drug is newly added or lacks a specific listing (unlisted/mid‑term additions)

How it's calculatedCalculated using the Base Rate% (e.g., 118% ASP / 90% AWP) and a negotiated multiplier

Hierarchy referenceDefault Rate follows the Base Rate hierarchy: % of ASP, then % of AWP, then % of Reasonable Charge

Reasonable Charge

Definition of Reasonable ChargeThe provider's usual charge to the general public; when fees are based on a percentage of Reasonable Charge, charges must be reasonable and not excessive

Use for miscellaneous codesDrugs billed under miscellaneous or unlisted codes will be reimbursed at a percentage of Reasonable Charge as indicated in the Network Participation Agreement

Audit rightsBlue Cross NC may audit and inspect records related to services and supplies per the Network Participation Agreement

External Pricing Sources

Primary external sourcesAverage Sales Price (ASP), Average Wholesale Price (AWP), and Wholesale Acquisition Cost (WAC)

Update frequencyExternal source pricing will be updated on a quarterly basis

Hierarchy useThese external sources are used to determine Base Rate Fees in the hierarchy (ASP first, then AWP, then Reasonable Charge)

OpenPayer

Pricing Development and Maintenance Policy for Drugs - Outpatient Services

Reimbursement Determination

Code Determination and Default Rate Calculation

Actions for Providers and Network Management

Key Definitions