FPV Practice Exam 1-03
6114667
2/8/20XX
Robert Sykes
George Katz
Take 1 capsule by mouth once daily.
Diltiazem CD 240 mg Capsules
30
5
2/8/20XX
Actavis
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 00228-2578-09
Quantity: 30
Days Supply: 30
AWP Cost/Unit: $2.05
Total Drug Cost: $61.50
Dispensing Fee: $2.00
Total Billed: $63.50
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 00228-2578-09
Quantity: 30
Days Supply: 30
AWP Cost/Unit: $2.05
Total Drug Cost: $61.50
Dispensing Fee: $2.00
Total Billed: $63.50
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 6114667
Dispensing Date: 2/8/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 2/8/20XX
Initials:
Drug Manu: Actavis
Rx Documentation
Dispensing Date: 2/8/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 2/8/20XX
Initials:
Drug Manu: Actavis