| Claim ID | Rx# | Status | Fill Date | Proc. Date | Drug Name | Mbr Cost | Pharmacy Name | Discount |
|---|---|---|---|---|---|---|---|---|
| 4499514500 | 2959697 | Reversed | 12/17/2014 | 12/17/2014 14:50:44 | TIMOLOL 0.5% EYE DROPS | $23.00 | TROPICANA DRUGS | Yes |
| 4499507075 | 2959697 | Reversed | 12/17/2014 | 12/17/2014 14:50:44 | TIMOLOL 0.5% EYE DROPS | $38.80 | TROPICANA DRUGS | No |
| 4492994005 | 2959697 | DENIED | 12/17/2014 | 12/17/2014 14:50:44 | TIMOLOL 0.5% EYE DROPS | $0.00 | TROPICANA DRUGS | Yes |
| 4492994005 | 2959697 | Reversed | 12/17/2014 | 12/17/2014 14:50:44 | TIMOLOL 0.5% EYE DROPS | $0.00 | TROPICANA DRUGS | No |
| 4499514500 | 2959697 | Reversed | 12/17/2014 | 12/17/2014 14:50:44 | TIMOLOL 0.5% EYE DROPS | $23.00 | TROPICANA DRUGS | Yes |
| 4499507075 | 2959697 | Reversed | 12/17/2014 | 12/17/2014 14:50:44 | TIMOLOL 0.5% EYE DROPS | $38.80 | TROPICANA DRUGS | No |
| 4492994005 | 2959697 | DENIED | 12/17/2014 | 12/17/2014 14:50:44 | TIMOLOL 0.5% EYE DROPS | $0.00 | TROPICANA DRUGS | Yes |
| 4492994005 | 2959697 | Reversed | 12/17/2014 | 12/17/2014 14:50:44 | TIMOLOL 0.5% EYE DROPS | $0.00 | TROPICANA DRUGS | No |
| 4492994005 | 2959697 | DENIED | 12/17/2014 | 12/17/2014 14:50:44 | TIMOLOL 0.5% EYE DROPS | $0.00 | TROPICANA DRUGS | Yes |
| 4492994005 | 2959697 | Reversed | 12/17/2014 | 12/17/2014 14:50:44 | TIMOLOL 0.5% EYE DROPS | $0.00 | TROPICANA DRUGS | No |
