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Accumulator - View By Claim

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Health Center:

Pharmacy:

Capture Date :

To:

			Health Center	Pharmacy	ShipTo	Claim Type	RX Number	Member ID	Fill	Fill Date	Adjud Date	Captured Date	NDC	Drug Name	Strength	Form	Pkg Size	QTY Disp	Curr QTY	% of Claim	Status	Status Date	Order	Wholesaler Invoice
False	10056548		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799489	MR00256491	00	08/01/2023	08/01/2023	08/02/2023	68001041504	DULOXETINE HCL DR 60 MG CAP	60 MG	CAPSULE DR	30	30	6	20.00000	Replenished	08/22/2023	1002252535	3142130208
False	9558112		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796251	MR00022006	01	05/30/2023	05/30/2023	06/01/2023	68001041504	DULOXETINE HCL DR 60 MG CAP	60 MG	CAPSULE DR	30	90	12	13.33400	Replenished	07/03/2023	1002239529	3138618794
False	9544276		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000798276	MR00256491	00	05/31/2023	05/31/2023	06/01/2023	68001041504	DULOXETINE HCL DR 60 MG CAP	60 MG	CAPSULE DR	30	12	12	100.00000	Replenished	06/05/2023	1002226246	3135522746
False	9949647		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000798276	MR00256491	01	07/14/2023	07/14/2023	07/16/2023	68001041504	DULOXETINE HCL DR 60 MG CAP	60 MG	CAPSULE DR	30	12	12	100.00000	Replenished	08/22/2023	1002252535	3142130208
False	9831513		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000798907	MR00308447	00	06/30/2023	06/30/2023	07/01/2023	68001041504	DULOXETINE HCL DR 60 MG CAP	60 MG	CAPSULE DR	30	30	12	40.00000	Replenished	08/22/2023	1002252535	3142130208
False	9558110		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796251	MR00022006	01	05/30/2023	05/30/2023	06/01/2023	68001041504	DULOXETINE HCL DR 60 MG CAP	60 MG	CAPSULE DR	30	90	18	20.00000	Replenished	06/05/2023	1002226246	3135522746
False	9825568		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000798907	MR00308447	00	06/30/2023	06/30/2023	07/01/2023	68001041504	DULOXETINE HCL DR 60 MG CAP	60 MG	CAPSULE DR	30	30	18	60.00000	Replenished	07/03/2023	1002239529	3138618794
False	5344474		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000787421	MR00071187	00	01/05/2022	01/05/2022	01/05/2022	68001041504	DULOXETINE HCL DR 60 MG CAP	60 MG	CAPSULE DR	30	90	30	33.33300	Replenished		1001985204	3079284650
False	5350087		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000787421	MR00071187	00	01/05/2022	01/05/2022	01/05/2022	68001041504	DULOXETINE HCL DR 60 MG CAP	60 MG	CAPSULE DR	30	90	30	33.33300	Replenished		1001985204	3079284650
False	5350088		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000787421	MR00071187	00	01/05/2022	01/05/2022	01/05/2022	68001041504	DULOXETINE HCL DR 60 MG CAP	60 MG	CAPSULE DR	30	90	30	33.33400	Replenished		1001985204	3079284650