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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	9920825		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797240	MR00067064	03	07/11/2023	07/11/2023	07/12/2023	00310737020	BUDESONIDE-FORMOTEROL 160-4.5	160-4.5MCG	HFA AER AD	10.2	10.2	10.2	100.00000	Replenished	08/22/2023	1002247471	3140061852
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	9653369		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797240	MR00067064	02	06/12/2023	06/12/2023	06/13/2023	00310737020	BUDESONIDE-FORMOTEROL 160-4.5	160-4.5MCG	HFA AER AD	10.2	10.2	10.2	100.00000	Replenished	06/14/2023	1002233505	3136619883
False	9375378		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797240	MR00067064	01	05/12/2023	05/12/2023	05/16/2023	00310737020	BUDESONIDE-FORMOTEROL 160-4.5	160-4.5MCG	HFA AER AD	10.2	10.2	10.2	100.00000	Replenished	05/18/2023	1002221191	3133750055
False	9115861		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797240	MR00067064	00	04/11/2023	04/11/2023	04/13/2023	00310737020	BUDESONIDE-FORMOTEROL 160-4.5	160-4.5MCG	HFA AER AD	10.2	10.2	10.2	100.00000	Replenished	04/17/2023	1002207066	3130202878
False	8574685		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000796092	MR00030324	00	02/13/2023	02/13/2023	02/13/2023	00310737020	BUDESONIDE-FORMOTEROL 160-4.5	160-4.5MCG	HFA AER AD	10.2	10.2	10.2	100.00000	Replenished		1002178681	3123384823
False	6044733		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789437	MR00067064	00	04/08/2022	04/08/2022	04/09/2022	00310737020	BUDESONIDE-FORMOTEROL 160-4.5	160-4.5MCG	HFA AER AD	10.2	10.2	10.2	100.00000	Replenished		1002032229	3089169383
False	6301648		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789437	MR00067064	01	05/12/2022	05/12/2022	05/13/2022	00310737020	BUDESONIDE-FORMOTEROL 160-4.5	160-4.5MCG	HFA AER AD	10.2	10.2	10.2	100.00000	Replenished		1002051432	3092898161
False	6512650		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789437	MR00067064	02	06/10/2022	06/10/2022	06/11/2022	00310737020	BUDESONIDE-FORMOTEROL 160-4.5	160-4.5MCG	HFA AER AD	10.2	10.2	10.2	100.00000	Replenished		1002066046	3095834366
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