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Get NCDP Universal Claim Form

D 3 = Substitution Allowed - Pharmacist Selected Product Dispensed 4 = Substitution Allowed - Generic Drug Not in Stock 5 = Substitution Allowed - Brand Drug Dispensed as a Generic 6 = Override, used to indicate MAC pricing applies. 7 = Substitution Not Allowed - Brand Drug Mandated by Law 8 = Substitution Allowed - Generic Drug Not Available in Marketplace 9 = Other N/A DATE WRITTEN Required N/A DATE OF SERVICE Required N/A FILL # Required Field 9 QTY DISPENSED Required N/A N/A Fie.

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