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3501173
6/28/20XX
Jill S. Mott
Harold L. Green
Inject 15 units subcutaneously for diabetes.
Semglee 100 units/mL Injection Pen
15 mL
3
6/21/20XX
Mylan
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 2
Pharmacy DAW Code: 0
Drug NDC: 49502-0251-75
Quantity: 15 mL
Days Supply: 100
AWP Cost/Unit: $32.32
Total Drug Cost: $484.80
Dispensing Fee: $2.00
Total Billed: $486.80
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 2
Pharmacy DAW Code: 0
Drug NDC: 49502-0251-75
Quantity: 15 mL
Days Supply: 100
AWP Cost/Unit: $32.32
Total Drug Cost: $484.80
Dispensing Fee: $2.00
Total Billed: $486.80
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 3501173
Dispensing Date: 6/28/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 6/28/20XX
Initials: RPh
Drug Manu: Mylan
Rx Documentation
Dispensing Date: 6/28/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 6/28/20XX
Initials: RPh
Drug Manu: Mylan
