Third-Party Insurance Prescriptions

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Information Required on Label
Dispensing Date:
Date Rx was Written:
Patient Name: (first & last)
Physician Name: (first & last)
Drug NDC#:
Drug Name:
Generic Name For:
Brand Name of:
Drug Strength:
Drug Dosage Form:
Drug Manufacturer:
Quantity Dispensed:
Refills:
Beyond-Use Date:
Sig: (Note: start with capital letter, end with period. Do not use ALL CAPS.)	Take 1 teaspoonful (5 mL) by mouth every 12 hours as needed for cough.
Custom Aux Sticker 1:
Auxiliary Label #1	Click Here To Find Aux Label
Auxiliary Label #2	Click Here To Find Aux Label
Auxiliary Label #3	Click Here To Find Aux Label
Auxiliary Label #4	Click Here To Find Aux Label
Medication Bottle Used To Fill Rx
Drug Bottle #:	Click Here To Find Bottle Number
Insurance Billing Information
Insurance Code:
Member Name:
Member ID:
Person Code:
Gender:
Rx BIN:
Rx PCN:
Rx Group:
Prescription Origin Code:
Days Supply:
Pharmacy DAW Code:
Dispensing Documentation
Rx Number:
Date of Dispensing:
RPh Initials:

Original Prescription

 at 12:46, eRx #:62950

ELECTRONIC PRESCRIPTION

Stanley M. Bontrager

421 E. 21st Street

Date: 3/2/20XX

Tussionex 10 mg-8 mg/5 mL ER Suspension

Dispense 120

Sig: 1 TSP PO Q12H PRN COUGH

Refills: 1

Dr.

DAW: dispense as written

Pharmacist Notes: 

DAW Codes

DAW 0 - NO DISPENSE AS WRITTEN
(substitution allowed or no generic on market)

DAW 1 - PHYSICIAN writes DISPENSE AS WRITTEN

DAW 2 - PATIENT REQUESTED BRAND

DAW 3 - PHARMACIST SELECTED BRAND

DAW 4 - GENERIC NOT IN STOCK

DAW 5 - BRAND DISPENSED, PRICED AS GENERIC

DAW 6 - OVERRIDE

DAW 7 - SUBSTITUTION NOT ALLOWED BY LAW

DAW 8 - GENERIC NOT AVAILABLE

DAW 9 - OTHER

Insurance Card

United Blue Expressmark
Prescription Drug Card

Member Name:  Stanley M. Bontrager
Member ID:  941149310
Person Code:  00 Stanley M., 01 Coleen L, 02 Julia M., 03 David M., 04 Joel N., 05 Rose J.
RxBIN:  893766
RxPCN:  SGFTYD
RxGROUP:  BMJW0QI3