View By Claim - BAR

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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	8426248		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788007	MR00079005	04	01/27/2023	01/27/2023	01/28/2023	00378180777	LEVOTHYROXINE 88 MCG TABLET	88 MCG	TABLET	90	90	90	100.00000	Replenished		1002168592	3121399810
False	8426228		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000791709	MR00005078	02	01/27/2023	01/27/2023	01/28/2023	00378180777	LEVOTHYROXINE 88 MCG TABLET	88 MCG	TABLET	90	90	90	100.00000	Replenished		1002168592	3121399810