Download:
pdf |
pdfEHB Prescription Drugs Template
NDC*
Required:
Unique 11-Digit Number that Identifies the Drug Being Included
in this Formulary
Enter numbers without dashes
Instructions: All fields with an asterisk ( * ) are required
Use one row for each covered Drug NDC
| File Type | application/pdf |
| File Title | Appendix C-3 (EHB Prescription Drug Template) |
| Subject | EHB, Prescription drugs, NDC, Formulary, Drug, Template, EHB prescription drugs, Essential Health Benefit, Submission, EHB presc |
| Author | Centers for Medicare and Medicaid Services |
| File Modified | 2012-07-29 |
| File Created | 2012-07-27 |