Remote Filling Verification - Click on Error(s)
5139947
4/15/20XX
Hilda R. Morgan
Norman Keyes
Inject 2.5 mg subcutaneously once weekly for 4 weeks.
Mounjaro 2.5 mg/0.5 mL Tablet
2 mL
0
4/12/20XX
Lilly
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 4
Pharmacy DAW Code: 0
Drug NDC: 00002-1506-80
Quantity: 2 mL
Days Supply: 28
AWP Cost/Unit: $306.91
Total Drug Cost: $1227.64
Dispensing Fee: $2.00
Total Billed: $1229.64
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 4
Pharmacy DAW Code: 0
Drug NDC: 00002-1506-80
Quantity: 2 mL
Days Supply: 28
AWP Cost/Unit: $306.91
Total Drug Cost: $1227.64
Dispensing Fee: $2.00
Total Billed: $1229.64
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 5139947
Dispensing Date: 4/15/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 4/15/20XX
Initials: RPh
Drug Manu: Lilly
Rx Documentation
Dispensing Date: 4/15/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 4/15/20XX
Initials: RPh
Drug Manu: Lilly
