FPV Practice Exam 1-05
43331932
2/8/20XX
James Hanson
Harold Green
Take 1 tablet by mouth 3 times a day as needed for anxiety.
Xanax 0.25 mg Tablet
40
0
2/6/20XX
Upjohn
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 1
Drug NDC: 00009-0029-01
Quantity: 40
Days Supply: 13
AWP Cost/Unit: $1.97
Total Drug Cost: $78.80
Dispensing Fee: $2.00
Total Billed: $80.80
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 1
Drug NDC: 00009-0029-01
Quantity: 40
Days Supply: 13
AWP Cost/Unit: $1.97
Total Drug Cost: $78.80
Dispensing Fee: $2.00
Total Billed: $80.80
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 43331932
Dispensing Date: 2/6/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 2/6/20XX
Initials: RPh
Drug Manu: Upjohn
Rx Documentation
Dispensing Date: 2/6/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 2/6/20XX
Initials: RPh
Drug Manu: Upjohn