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2031177
8/20/20XX
Mark Sawyer
Cynthia McDonald
Take 1 tablet by mouth once daily for chronic pain.
Hydromorphone 8 mg Extended-Release Tablet
30
0
8/19/20XX
Padagis
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 3
Pharmacy DAW Code: 0
Drug NDC: 00574-0293-01
Quantity: 30
Days Supply: 30
AWP Cost/Unit: $8.25
Total Drug Cost: $247.50
Dispensing Fee: $2.00
Total Billed: $249.50
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 3
Pharmacy DAW Code: 0
Drug NDC: 00574-0293-01
Quantity: 30
Days Supply: 30
AWP Cost/Unit: $8.25
Total Drug Cost: $247.50
Dispensing Fee: $2.00
Total Billed: $249.50
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 2031177
Dispensing Date: 8/20/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 8/20/20XX
Initials: RPh
Drug Manu: Padagis
Rx Documentation
Dispensing Date: 8/20/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 8/20/20XX
Initials: RPh
Drug Manu: Padagis
