Original Prescription
at 9:16, eRx #: 4677
ELECTRONIC PRESCRIPTION
Janet T. Jones
2032 Missouri Street
Date: 4/12/20XX
Byetta 10 mcg/dose Pen
Dispense 1 month supply
Sig: Inject 10 mcg SC BID UD
Refills: 3
Dr. Carolyn Abman
1315 W. 12th Street
BA4132647
DAW: substitution permitted
Prescription Origin Code: 3
Pharmacist Notes:
Dispensing Documentation
Rx #: 963442
Dispensing Date: 7/15/20XX
Patient: Janet T. Jones
Doctor: Carolyn Abman
DEA: BA4132647
NDC: 66780-0212-01
RPh Initials: DKL
Drug: Byetta Pen 250 mcg/mL Injection Solution
Manufacturer: Lilly
DAW Code: 0
SIG: Inject,10 mcg dose,SC,BID,UD
Fill Type: Refill
Fill Number: 3
Last Fill Date: 6/12/20XX
Refills Remaining: 1
Quantity: 60
Day Supply: 30
Drug Unit Cost: $157.63
Dispensing Fee: $1.75
Total Cost: $9459.55
Signature Log
Signature:
Janet Jones
Rx Number:
963442
Fill Date Date:
7/15/20XX
Pick-up Date:
7/17/20XX
RPh Counseling:
Decline