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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	8807359		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789437	MR00067064	11	03/10/2023	03/10/2023	03/11/2023	00310737020	BUDESONIDE-FORMOTEROL 160-4.5	160-4.5MCG	HFA AER AD	10.2	10.2	10.2	100.00000	Replenished		1002187584	3126302342
False	8552447		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789437	MR00067064	10	02/09/2023	02/09/2023	02/11/2023	00310737020	BUDESONIDE-FORMOTEROL 160-4.5	160-4.5MCG	HFA AER AD	10.2	10.2	10.2	100.00000	Replenished		1002178117	3123055057
False	8279741		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789437	MR00067064	09	01/10/2023	01/10/2023	01/11/2023	00310737020	BUDESONIDE-FORMOTEROL 160-4.5	160-4.5MCG	HFA AER AD	10.2	10.2	10.2	100.00000	Replenished		1002162186	3119565263
False	8044834		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789437	MR00067064	08	12/12/2022	12/12/2022	12/13/2022	00310737020	BUDESONIDE-FORMOTEROL 160-4.5	160-4.5MCG	HFA AER AD	10.2	10.2	10.2	100.00000	Replenished		1002149821	3116206380
False	7773186		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789437	MR00067064	07	11/09/2022	11/09/2022	11/10/2022	00310737020	BUDESONIDE-FORMOTEROL 160-4.5	160-4.5MCG	HFA AER AD	10.2	10.2	10.2	100.00000	Replenished		1002130385	3112283351
False	7528338		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789437	MR00067064	06	10/11/2022	10/11/2022	10/12/2022	00310737020	BUDESONIDE-FORMOTEROL 160-4.5	160-4.5MCG	HFA AER AD	10.2	10.2	10.2	100.00000	Replenished		1002120414	3109055000
False	7338527		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789437	MR00067064	05	09/15/2022	09/15/2022	09/16/2022	00310737020	BUDESONIDE-FORMOTEROL 160-4.5	160-4.5MCG	HFA AER AD	10.2	10.2	10.2	100.00000	Replenished		1002108257	3106376963
False	7059558		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789437	MR00067064	04	08/08/2022	08/08/2022	08/09/2022	00310737020	BUDESONIDE-FORMOTEROL 160-4.5	160-4.5MCG	HFA AER AD	10.2	10.2	10.2	100.00000	Replenished		1002088256	3102157587
False	10154871		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797240	MR00067064	04	08/14/2023	08/14/2023	08/15/2023	00310737020	BUDESONIDE-FORMOTEROL 160-4.5	160-4.5MCG	HFA AER AD	10.2	10.2	10.2	100.00000	Replenished	08/16/2023	1002259761	3143593678
False	6855183		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789437	MR00067064	03	07/11/2022	07/11/2022	07/12/2022	00310737020	BUDESONIDE-FORMOTEROL 160-4.5	160-4.5MCG	HFA AER AD	10.2	10.2	10.2	100.00000	Replenished		1002078923	3099104399