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Transmitted Dale Message
Pay Method United Healthcare - -- - - - I
Rx Number - [lain - Get mionriation about the 
Help Deals Phone. I 
Third Parly Phone (330-. 797.9791 Headed: 70. This medication requires mor aulhonzaion. Please click the bulion tomitide. 5
Submitted Paid IL'ne l.UseAddeml1XH?lan Exchaion I:
Base: 52391? 50.00 codes 
FeeSubtotal: 5249 16 50 DD Explanation Possible Error
Tax 513.08 SO 00
Total' 5252 24 SD 00
Copay. SO 00 .
Patient . . I .. . I
- Resp?oust Messages
Patient -- - . 
Balm For 5mg Free Text Message Clinical Signi?cance Previous Date Of Fill 55:3an 0f PrcVIcus .
. . . Ia. I - .I . 1-5-11. h'iam;9 11113:GEE.-- .. - . 

PnorAu?IorizatianCode: 0- NolSpeci?ed Number: 9 ThisFill 1r

 



 

 

Clari?oltion Code o= Not Speci?ed 4 Fill .
ProductiD Quali?cation: D3 Nauonal Drug Code This Fill 
Ex- magi; ?h I .. a O?terCmerage Code: 0 Nol Speci?ed This Fill 333?? :0 Incentive Amount 0 00 This 
Moo 901151d8701 OUR Th. . - - -
Scope: 5 Fill 
.. -. - - .- . . . .. . . . -
Maorizalion: _Drug Utilization Rariews NEWF5 .- I .
Reason Ifor Service ProersIinonal Service RIesult of Service Lewd Of Effort
mm- um: L..- .--.LL PumCIaLm-Fa I [Liam-"Lu F5 F7 - I -. 

 

 

 

 

 

CIairn Summary EDI Renew-?!

 

 

Transmitted Dale: 
Pay Method United Healthcare
RxNumber 

. HelpDak Phone

1 Third Pa?yPhune: (800)797-9791

Submitted Paid

1 Base: $333.35 521489

Fee: $999 51 ED

Subtotal: $34334 5215 89
Tax: 51803 5118?
Total 5361 37 5192.86
Cup-av. 535 CID

Patient

1 Patient

.3 Birthday.

Gender.
CadeoldettD'.

Ralatiomhip:

1 GrouplD:

I . 

'Prescriber
Prescribe:
NPI:



IRxIanm?ITti; - 
Rxltem: Io M010
DaysSupply? 30 
Pat 0
NBC: 54092038301

9 .
W: 1?

 

 

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- F5 *1 -- RthFIa 13933-36