MEDICATION # PHARMACY

Tranxene 15mg #90 Walgreens

Dexedrine ER 10mg (dextroamphetamine) #60 Mr Discount
Lortab 10/500 (hydrocodone/APAP) #25 Freds
Ativan 2mg #90 Walgreens
Tranxene 15mg #90 Mr Discount
B12 injectable (cyanocobalamin) 10cc CVS
Ambien 10mg #30 CVS
Dexedrine ER 10mg (dextroamphetamine) #60 Mr Discount
Bentyl 10mg (dicyclomine) #60 Freds
Dexedrine ER 10mg (dextroamphetamine) #07 CVS
Tranxene 15mg #60 Walgreens
Zanaflex/tizanidine 4mg #90 CVS
Tramadol 50mg (Ultram) #180 CVS
Ambien 10mg #30 CVS
Chloral Hydrate 500mg #100 MEDICAP
Lortab 7.5/500 (hydrocodone/APAP) #15 Walgreens
Lexapro 20mg #135 CVS
Neurontin 300mg (Gabapentin) #270 CVS
Tramadol 50mg (Ultram) #180 CVS
Ambien 10mg #30 CVS
Zanaflex/tizanidine 4mg #90 CVS
Chloral Hydrate 500mg #100 MEDICAP
Tranxene 15mg #90 Walgreens
Dexedrine ER 10mg (dextroamphetamine) #120 Mr Discount
Zanaflex/tizanidine 4mg #90 CVS
Zanaflex/tizanidine 4mg #90 Mr Discount
Neurontin 300mg (Gabapentin) #270 CVS
Dexedrine Spansule 10mg (BRAND) #60 CVS
Ambien 10mg #30 CVS
B12 injectable (cyanocobalamin) 10cc CVS
Clonidine 0.1mg #180 CVS
Ambien 10mg #30 CVS
Lexapro 20mg #180 CVS
Chloral Hydrate 500mg #100 MEDICAP
Lortab 10/500 (hydrocodone/APAP) #25 MEDICAP
Tramadol 50mg (Ultram) #180 CVS
Ativan 2mg #120 CVS
Lortab 10/500 (hydrocodone/APAP) #25 Walgreens
Ativan 2mg #120 Walgreens
Tranxene 15mg #90 Walgreens
Dexedrine ER 10mg (dextroamphetamine) #60 Mr Discount
Methylprednisolone 4mg-Medrol Dosepak #21 Mr Discount
Lortab 10/500 (hydrocodone/APAP) #25 Mr Discount
Tranxene 15mg #90 Walgreens
Chloral Hydrate 500mg #100 MEDICAP
Ativan 2mg #120 Walgreens
Lortab 10/500 (hydrocodone/APAP) #30 Mr Discount
Ativan 2mg #120 Mr Discount
Tranxene 15mg #90 Mr Discount
Ativan 2mg #120 CVS
Levsin 0.125mg SL (LEVSIN) #50 Mr Discount
Lortab 10/500 (hydrocodone/APAP) #30 Mr Discount
Dexedrine ER 10mg (dextroamphetamine) #120 Mr Discount
Tramadol 50mg (Ultram) #180 Mr Discount
Zanaflex/tizanidine 4mg #90 Mr Discount
Dexedrine ER 10mg (dextroamphetamine) #60 Mr Discount
Chloral Hydrate 500mg #50 MEDICAP
Lortab 10/500 (hydrocodone/APAP) #30 Walgreens
Ativan 2mg #120 Walgreens
Tranxene 15mg #90 Walgreens
Chloral Hydrate 500mg #50 MEDICAP
Chloral Hydrate 500mg #50 MEDICAP
Neurontin 300mg (Gabapentin) #270 CVS
Lexapro 20mg #180 CVS
APAP/Isometh/chloral hydrate (Midrin) #90 Vital Care
B12 injectable (cyanocobalamin) 1cc Mr Discount
Dexedrine ER 10mg (dextroamphetamine) #120 Mr Discount
Chloral Hydrate 500mg #100 MEDICAP

CHARGES EXCLUDED IN SUBMITTED CLAIM ERRONEOUSLY WHEN PAID FULL AMT (Amounts ex
Ativan 2mg #120 Walgreens
Tranxene 15mg #90 Walgreens
Chloral Hydrate 500mg #50 MEDICAP
Lortab 10/500 (hydrocodone/APAP) #30 Walgreens

Flexpay
Dexedrine ER 10mg (dextroamphetamine) #60 Mr Discount
Zanaflex/tizanidine 4mg #30 Freds
Tranxene 7.5mg #60 Freds
APAP/Isometh/chloral hydrate (Midrin) #90 Vital Care
APAP/Isometh/chloral hydrate (Midrin) #90 Vital Care
APAP/Isometh/chloral hydrate (Midrin) #90 Vital Care
Dexedrine ER 10mg (dextroamphetamine) #60 Mr Discount
Lortab 7.5/500 (hydrocodone/APAP) #10 Mr Discount
APAP/Isometh/chloral hydrate (Midrin) #90 Vital Care
APAP/Isometh/chloral hydrate (Midrin) #90 Vital Care
APAP/Isometh/chloral hydrate (Midrin) #90 Vital Care
Ambien 10mg #30 CVS
Clonidine 0.1mg #60 CVS
Lexapro 20mg #45 CVS
Ativan 2mg #120 CVS
Dexedrine ER 10mg (dextroamphetamine) #60 Mr Discount
Bentyl 10mg (dicyclomine) #60 Freds
Tramadol / Ultram 50mg #45 CVS
Zanaflex/tizanidine 4mg #45 CVS
Tranxene 7.5mg #60 CVS
Lexapro 20mg #45 CVS
Clonidine 0.1mg #60 CVS
Ambien 10mg #30 CVS
Dexedrine ER 10mg (dextroamphetamine) #60 CVS
Ativan 2mg #120 CVS
Zanaflex/tizanidine 4mg #90 CVS
Ambien 10mg #30 CVS
Tramadol / Ultram 50mg #180 CVS
Neurontin 300mg (gabapentin) #90 CVS
Clonidine 0.1mg #180 CVS
Tramadol / Ultram 50mg #180 CVS
Ambien 10mg #30 CVS
Ativan 1mg #90 CVS
Ativan 2mg #90 Freds
Lexapro 20mg #45 Freds
Tranxene 15mg #60 Walgreens
Zanaflex/tizanidine 4mg #45 CVS
Tramadol / Ultram 50mg #45 CVS
Dexedrine ER 10mg (dextroamphetamine) #60 Walgreens
Ativan 2mg #90 CVS
Ambien 10mg #30 CVS
Clindamycin (CLEOCIN) 300mg #40 Freds
B12 injectable (cyanocobalamin) 10cc CVS
Ativan 2mg #90 CVS
Tranxene 15mg #60 Walgreens
Zanaflex/tizanidine 4mg #45 CVS
Tramadol / Ultram 50mg #45 CVS
Lexapro 20mg #45 CVS
Zanaflex/tizanidine 4mg #90 CVS
Tramadol / Ultram 50mg #90 CVS
Ambien 10mg #30 CVS
Tranxene 15mg #90 Walgreens
Zanaflex/tizanidine 4mg #90 CVS
Tramadol / Ultram 50mg #90 CVS
Lexapro 20mg #135 CVS
Tranxene 15mg #90 Walgreens

OTHER
Syringes for B12 Inj Freds
Syringes for B12 Inj CVS
Syringes for Testosterone Freds
Syringes Mr Discount
RX# PRICE PLAN SAVED PHYSICIAN
0174818-12537 $10.74 $101.75 Grace Kelly
N633708 00 $42.70 $189.49 Grace Kelly
4531305 $4.48 $13.81 T French
0178520-12537 $5.00 $75.50 Grace Kelly
C649367 00 $10.74 $101.75 T French
0356166 01 $3.25 T French
C0358298 02 $2.48 Grace Kelly
N650491 00 $42.70 $189.49 Grace Kelly
6590735 $3.29 Crowson
N0376667 00 $5.00 T French
0181618-12537 $7.23 $69.76 Grace Kelly
0362903 01 $5.00 T French
C0362902 01 $5.00 T French
C0376991 00 $2.48 Grace Kelly
4221741 $22.87 97.87 [91.46] T French
0549247-07580 $2.43 $9.57 N Pettigrew
0361918 01 $79.23 90day supply Grace Kelly
0374925 00 $10.00 90day supply Grace Kelly
0362902 02 $5.00 T French
C0379488 00 $2.48 Grace Kelly
0362903 02 $5.00 T French
4222483 $20.07 $100.67 T French
0184032-12537 $10.74 $101.75 Grace Kelly
N696320 00 $85.20 $383.96 Grace Kelly
0362903 03 $5.00 T French
712320 00 $5.00 T French
0389125 00 $10.00 Grace Kelly
N0377383 00 $239.68 not covered Grace Kelly
C0389126 01 $2.48 Grace Kelly
0356166 02 $3.25 J L Valentine
0365837 01 $10.00 90day supply Grace Kelly
C0389126 00 $2.48 Grace Kelly
0389124 00 $42.84 $171.35 Grace Kelly
4223220 $22.87 $97.87 T French
4223218 $5.00 $2.52 T French
 C0362902 03 $5.00 [10.54] T French
C0379487 00 $5.00 $93.66 Grace Kelly
0188035-12537 $5.00 $13.29 T French
0191955-12537 $5.00 $93.66 Grace Kelly
0191956-12537 $10.74 $101.75 Grace Kelly
N681651 00 $42.70 $189.49 Grace Kelly
670693 00 $5.00 T French
C670695 00 $4.48 $13.81 T French
0187962-12537 $10.74 $101.75 Grace Kelly
4222483 $20.07 100.67 [80.26] T French
0187963-12537 $5.00 $93.66 Grace Kelly
C712314 00 $5.00 $4.00 T French
C733880 00 $5.00 $93.66 Grace Kelly
C733879 00 $10.74 101.75 [42.95] Grace Kelly
C0371165 00 $5.00 $93.66 Grace Kelly
734653 00 $6.15 $24.60 T French
C734651 00 $5.00 $4.00 T French
N734657 00 $85.20 $383.96 Grace Kelly
C712321 00 $5.00 [10.54] T French
712320 01 $5.00 [12.25] T French
N696320 00 $85.20 $383.96 Grace Kelly
4223953 $11.53 $46.14 T French
0197770-12537 $20.75 0-LAPSE T French
0191955-12537 $98.66 0-LAPSE Grace Kelly
0191956-12537 $112.49 0-LAPSE Grace Kelly
4223429 $52.45 0-LAPSE T French
4223953 $0.00 $57.67 T French
0389125 01 $0.00 $34.09 Grace Kelly
0389124 01 $0.00 $214.19 Grace Kelly
C117050 $126.00 0-COMPOUNDED J L Valentine
$11.95 0-LAPSE T French
$469.95 0-LAPSE Grace Kelly
4221741 $0.87 $97.87 T French

ID FULL AMT (Amounts excluded are usually covered)

 <--Amount
owed to me
per benefit
C0191955 $83.69 for claim Grace Kelly
C0191956 $57.33 <-- Grace Kelly
4223429 $1.78 <-- T French
C0197770 $11.75 <-- T French

N615038 00 $233.99 0-Need PA Grace Kelly

6595129 $11.99 J L Valentine
4528077 $18.99 $55.77 Leigh Gillespie
C116269 $126.00 0-COMPOUNDED J L Valentine
C116269 $126.00 0-COMPOUNDED J L Valentine
C116269 $126.00 0-COMPOUNDED J L Valentine
N598169 00 $42.70 $189.49 Grace Kelly
C614219 00 $1.95 S Anderson-MMA
C117050 $126.00 0-COMPOUNDED J L Valentine
C117050 $126.00 0-COMPOUNDED J L Valentine
C117050 $126.00 0-COMPOUNDED J L Valentine
C0358298 00 $2.48 Grace Kelly
0358297 00 $4.71 Grace Kelly
0352775 01 $37.90 Grace Kelly
C0358300 00 $5.00 $93.66 Grace Kelly
N598169 00 $42.70 $189.49 Grace Kelly
6590735 $3.29 Crowson
C0346285 00 $4.63 J L Valentine
346286 00 $5.00 J L Valentine
C0346678 00 $5.00 $69.76 Leigh Gillespie
0346677 00 $34.98 Leigh Gillespie
0346679 00 $4.71 Leigh Gillespie
C0348581 00 $2.48 Leigh Gillespie
N0348582 00 $24.20 $189.49 Leigh Gillespie
C0358300 02 $5.00 $93.66 Grace Kelly
0362903 00 $5.00 T French
C0358298 01 $2.48 Grace Kelly
C030902 00 $5.00 [10.54] T French
0362866 01 $5.00 Grace Kelly
0365837 00 $9.94 Grace Kelly
C0362902 00 $5.00 [10.54] T French
C0358298 01 $2.48 Grace Kelly
C0348198 00 $5.00 Leigh Gillespie
4527970 $5.00 $75.50 Leigh Gillespie
6598991 $37.90 Leigh Gillespie
0163289-12537 $7.23 $69.76 Grace Kelly
0351405 00 $5.00 J L Valentine
0351404 00 $4.63 J L Valentine
0163935-12537 $42.70 $189.49 Grace Kelly
C0352777 00 $5.00 $75.50 Grace Kelly
C0352776 00 $2.48 Grace Kelly
6600407 $5.00 Terry Pitts
0356166 00 $3.25 J L Valentine
C0352777 01 $5.00 $75.50 Grace Kelly
0163289-12537 $7.23 $69.76 Grace Kelly
0355207 00 $5.00 J L Valentine
0355206 00 $4.63 J L Valentine
0352775 00 $37.90 Grace Kelly
0356167 00 $5.00 [12.25] J L Valentine
C0356168 00 $5.00 J L Valentine
C0352776 01 $2.48 Grace Kelly
0168214-12537 $10.74 $101.75 Grace Kelly
0362375 00 $5.00 [12.25] J L Valentine
C0362374 00 $5.00 J L Valentine
0361918 00 $79.23 Grace Kelly
0168214-12537 $10.74 $112.49 Grace Kelly

N/A $0.37 N/A

N/A $2.14 N/A
N/A $3.21 N/A
N/A $2.00 N/A
TOTAL $3,733.39
Date
05/29/2012
05/29/2012
06/19/2012
07/02/2012
06/30/2012
06/30/2012
06/29/2012
07/03/2012
06/30/2012
06/30/2012
07/28/2012
07/14/2012
08/02/2012
08/02/2012
07/13/2012
08/03/2012
07/23/2012
07/23/2012
09/04/2012
09/04/2012
08/17/2012
08/15/2012
08/17/2012
10/02/2002
09/24/2012
10/31/2012
10/16/2012
08/06/2012
12/07/2012
12/08/2012
12/08/2012
10/16/2012
10/16/2012
10/17/2012
10/17/2012
10/16/2012
08/22/2012
09/18/2012
10/16/2012
10/16/2012
09/04/2012
08/14/2012
08/14/2012
09/17/2012
09/18/2012
09/17/2012
10/31/2012
12/10/2012
12/10/2012
07/24/2012
12/11/2012
12/11/2012
12/11/2012
12/07/2012
12/07/2012
10/02/2012
12/11/2012
11/27/2012
11/14/2012
11/14/2012
11/08/2012
12/29/2012
12/31/2012
12/31/2012
05/15/2012
11/15/2012
11/15/2012
06/14/2012
11/14/2012
11/14/2012
11/08/2012
11/27/2012

04/22/2012
01/05/2012
01/05/2012
01/17/2012
02/14/2012
03/15/2012
03/21/2012
04/20/2012
04/16/2012
07/02/2012
05/15/2012
04/30/2012
04/30/2012
04/05/2012
04/10/2012
03/21/2012
03/30/2012
01/09/2012
01/09/2012
01/11/2012
01/11/2012
01/11/2012
01/25/2012
01/25/2012
06/05/2012
06/05/2012
06/04/2012
06/05/2012
06/06/2012
05/26/2012
06/05/2012
06/05/2012
01/23/2012
01/30/2012
02/10/2012
02/16/2012
02/14/2012
02/14/2012
02/22/2012
02/22/2012
02/22/2012
03/05/2012
03/16/2012
03/21/2012
03/09/2012
03/09/2012
03/09/2012
03/02/2012
03/28/2012
03/28/2012
03/30/2012
03/30/2012
05/01/2012
05/01/2012
05/02/2012
04/30/2012

03/30/2012
12/08/2012
01/30/2012
11/09/2012