Table
| Claim ID | Rx# | Status | Fill Date | Proc. Date | Drug Name | Mbr Cost | Pharmacy Name | Discount |
|---|---|---|---|---|---|---|---|---|
| 4499514500 | 2959697 | Reversed | 12/12/2014 | 12/12/2014 | Accupril (Quinapril Hydrochloride) - 10mg | $48.25 | Pfizer | Yes |
| 4499507075 | 2959705 | Reversed | 10/23/2014 | 10/23/2014 | Cefakind (250mg) | $82 | Mankind | Yes |
| 4499507075 | 2959713 | Denied | 12/12/2014 | 12/12/2014 | Ampicillin (Ampicillin) - 500mg | $116 | Omega Biotech Ltd. | No |
| 4499507076 | 2959721 | Reversed | 11/26/2014 | 11/26/2014 | Fluconazole - 50mg | $150 | Pacific Pharmaceuticals | No |
| 4499507077 | 2959729 | Denied | 10/23/2014 | 10/23/2014 | Accupril (Quinapril Hydrochloride) - 10mg | $184 | Pfizer | Yes |
| Claim ID | Rx# | Status | Fill Date | Proc. Date | Drug Name | Mbr Cost | Pharmacy Name | Discount |
|---|---|---|---|---|---|---|---|---|
| 4499514500 | 2959697 | Reversed | 12/12/2014 | 12/12/2014 | Accupril (Quinapril Hydrochloride) - 10mg | $48.25 | Pfizer | Yes |
| 4499507075 | 2959705 | Reversed | 10/23/2014 | 10/23/2014 | Cefakind (250mg) | $82 | Mankind | Yes |
| 4499507075 | 2959713 | Denied | 12/12/2014 | 12/12/2014 | Ampicillin (Ampicillin) - 500mg | $116 | Omega Biotech Ltd. | No |
| 4499507076 | 2959721 | Reversed | 11/26/2014 | 11/26/2014 | Fluconazole - 50mg | $150 | Pacific Pharmaceuticals | No |
| 4499507077 | 2959729 | Denied | 10/23/2014 | 10/23/2014 | Accupril (Quinapril Hydrochloride) - 10mg | $184 | Pfizer | Yes |
Showing 1 to 5 of 14 entries