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	9081870		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795110	MR00112542	01	04/01/2023	04/01/2023	04/11/2023	00169418113	OZEMPIC 0.25-0.5 MG/DOSE PEN	.25 OR 0.5	PEN INJCTR	3	3	3	100.00000	Replenished	04/12/2023	1002200467	3129734792
False	9439779		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797223	MR00034701	01	05/12/2023	05/12/2023	05/22/2023	00169418113	OZEMPIC 0.25-0.5 MG/DOSE PEN	.25 OR 0.5	PEN INJCTR	3	3	3	100.00000	Replenished	05/22/2023	1002209232	3130801353
False	9686021		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797223	MR00034701	02	06/14/2023	06/14/2023	06/16/2023	00169418113	OZEMPIC 0.25-0.5 MG/DOSE PEN	.25 OR 0.5	PEN INJCTR	3	3	3	100.00000	Replenished	06/19/2023	1002234814	3137091283
False	9544253		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000798302	MR00296604	00	05/31/2023	05/31/2023	06/01/2023	00169418113	OZEMPIC 0.25-0.5 MG/DOSE PEN	.25 OR 0.5	PEN INJCTR	3	3	3	100.00000	Replenished	06/05/2023	1002226246	3135522746
False	9595266		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000798345	MR00112542	00	06/05/2023	06/05/2023	06/06/2023	00169418113	OZEMPIC 0.25-0.5 MG/DOSE PEN	.25 OR 0.5	PEN INJCTR	3	3	3	100.00000	Replenished	06/08/2023	1002227496	3135977002