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4201158
7/9/20XX
Omar Khan
James T. Warren
Instill 1 drop into each eye 4 times each day.
Verkazia 0.1% Ophthalmic Emulsion
120 vials
5
7/9/20XX
Santen
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 65086-0001-12
Quantity: 120 vials
Days Supply: 30
AWP Cost/Unit: $14.65
Total Drug Cost: $1758.00
Dispensing Fee: $2.00
Total Billed: $1760.00
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 65086-0001-12
Quantity: 120 vials
Days Supply: 30
AWP Cost/Unit: $14.65
Total Drug Cost: $1758.00
Dispensing Fee: $2.00
Total Billed: $1760.00
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 4201158
Dispensing Date: 7/9/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 7/9/20XX
Initials: RPh
Drug Manu: Santen
Rx Documentation
Dispensing Date: 7/9/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 7/9/20XX
Initials: RPh
Drug Manu: Santen
