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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	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	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	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	8885358		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796774	MR00152015	00	03/20/2023	03/20/2023	03/21/2023	00310737020	BUDESONIDE-FORMOTEROL 160-4.5	160-4.5MCG	HFA AER AD	10.2	10.2	10.2	100.00000	Replenished		1002193992	3127402543
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	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	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