Sales Order Template Stops

Template Check Next Allowable

No. Patient Payor Policy No. Branch Reference Date Run Date Stop Type Amt

28133 Bermudez, Casandra D TRICARE EAST (HUMANA) 340867540 Fort Campbell KY 6 MTH RESUPPLY 11/29/2023 04/26/2024 Ineligible Policy $18.00
34460 Bermudez, Casandra D TRICARE EAST (HUMANA) 340867540 Fort Campbell KY BILL 11/29/2023 11/30/2023 Ineligible Policy $19.80
28387 Johnson-Pina, Eunice Ruby TRICARE EAST (HUMANA) 01462384001 Fort Cavazos TX 6 MTH RESUPPLY 11/29/2023 04/27/2024 Ineligible Policy $18.00
34480 Johnson-Pina, Eunice Ruby TRICARE EAST (HUMANA) 01462384001 Fort Cavazos TX BILL 11/29/2023 11/30/2023 Ineligible Policy $19.80
1830 Purcell, Aimee M TRICARE EAST (HUMANA) 345548998 Chantilly VA 11/30/2023 12/01/2023 Ineligible Policy $408.78
5421 Purcell, Aimee M TRICARE EAST (HUMANA) 345548998 Chantilly VA 11/30/2023 03/01/2024 Ineligible Policy $408.78
18142 Pavey, Wyatt A TRICARE EAST (HUMANA) 483089049 Fort Liberty 11/30/2023 12/01/2023 Ineligible Policy $176.84
18147 REBOREDO, RANDOLF T TRICARE EAST (HUMANA) 586539372 Fort Cavazos TX 11/30/2023 12/01/2023 Ineligible Policy $215.19
21639 Spaugh Jr, Phillip L TRICARE EAST (HUMANA) 241619800 Chantilly VA 11/30/2023 12/01/2023 Ineligible Policy $206.83
18085 CRESCINI, ABIGAIL J TRICARE EAST (HUMANA) 214512427 Chantilly VA 6 MTH RESUPPLY 11/30/2023 12/29/2023 Ineligible Policy $18.00
29580 CRESCINI, ABIGAIL J TRICARE EAST (HUMANA) 214512427 Chantilly VA BILL 11/30/2023 12/01/2023 Ineligible Policy $18.00
7066 RYCHARD, JASMINE A TRICARE EAST (HUMANA) 623165329 Chantilly VA 6 MTH RESUPPLY 11/30/2023 12/29/2023 Ineligible Policy $18.00
29586 RYCHARD, JASMINE A TRICARE EAST (HUMANA) 623165329 Chantilly VA BILL 11/30/2023 12/01/2023 Ineligible Policy $18.00
29587 MC WHIRTER, ERIKA L TRICARE EAST (HUMANA) 631071829 Chantilly VA BILL 11/30/2023 12/01/2023 Ineligible Policy $18.00
29588 SMITH, WHITNEY P TRICARE EAST (HUMANA) 224354095 Chantilly VA BILL 11/30/2023 12/01/2023 Ineligible Policy $18.00
29589 WHITCOMB, ANDREA I TRICARE WEST (HEALTH 01456734300 Chantilly VA BILL 11/30/2023 12/01/2023 Ineligible Policy $19.80
NET)

17462 GRAY, SAMANTHA L TRICARE EAST (HUMANA) 303191337 Fort Campbell KY 6 MTH RESUPPLY 11/30/2023 12/29/2023 Ineligible Policy $18.00
29624 GRAY, SAMANTHA L TRICARE EAST (HUMANA) 303191337 Fort Campbell KY BILL 11/30/2023 12/01/2023 Ineligible Policy $18.00
19505 BORDAS, BETHANY S TRICARE EAST (HUMANA) 599305020 Fort Campbell KY 6 MTH RESUPPLY 11/30/2023 12/29/2023 Ineligible Policy $18.00
29625 BORDAS, BETHANY S TRICARE EAST (HUMANA) 599305020 Fort Campbell KY BILL 11/30/2023 12/01/2023 Ineligible Policy $18.00
20922 BAXLEY, ELIZABETH M TRICARE EAST (HUMANA) 248916224 Fort Campbell KY 6 MTH RESUPPLY 11/30/2023 12/29/2023 Ineligible Policy $18.00
29627 BAXLEY, ELIZABETH M TRICARE EAST (HUMANA) 248916224 Fort Campbell KY BILL 11/30/2023 12/01/2023 Ineligible Policy $18.00
29713 Canterbury, Casandra TRICARE EAST (HUMANA) 525955550 Fort Liberty BILL 11/30/2023 12/01/2023 Ineligible Policy $18.00
21214 Dison, Emily E TRICARE EAST (HUMANA) 536435380 Fort Liberty 6 MTH RESUPPLY 11/30/2023 12/29/2023 Ineligible Policy $18.00
29724 Dison, Emily E TRICARE EAST (HUMANA) 536435380 Fort Liberty BILL 11/30/2023 12/01/2023 Ineligible Policy $18.00
18200 Kimura, Nonoka TRICARE EAST (HUMANA) 124983355 Fort Liberty 6 MTH RESUPPLY 11/30/2023 12/28/2023 Ineligible Policy $18.00
29738 Kimura, Nonoka TRICARE EAST (HUMANA) 124983355 Fort Liberty BILL 11/30/2023 12/01/2023 Ineligible Policy $18.00
29747 San Nicolas, Aubriana Maria R TRICARE EAST (HUMANA) 586474705 Fort Liberty BILL 11/30/2023 12/01/2023 Ineligible Policy $18.00
27906 Saddler, Katrina N TRICARE EAST (HUMANA) 603702718 Fort Liberty 6 MTH RESUPPLY 11/30/2023 12/22/2023 Ineligible Policy $18.00
29749 Saddler, Katrina N TRICARE EAST (HUMANA) 603702718 Fort Liberty BILL 11/30/2023 12/01/2023 Ineligible Policy $18.00
29796 HOLLOMAN, LATEEFAH S TRICARE OVERSEAS 182664751 Fort Stewart GA BILL-8/2 SEND 11/30/2023 12/01/2023 Ineligible Policy $19.80
EURASIA-AFRICA RX TO OVERSEAS

29890 BOWMAN, NIRA C TRICARE EAST (HUMANA) 673121911 Fort Cavazos TX BILL 11/30/2023 12/01/2023 Ineligible Policy $18.00

Printed On 11/30/2023 Page 1 of 3

 Sales Order Template Stops
35497 BOWMAN, NIRA C TRICARE EAST (HUMANA) 673121911 Fort Cavazos TX 6 MTH RESUPPLY 11/30/2023 01/03/2024 Ineligible Policy $19.80
30622 Tun, Aye T TRICARE EAST (HUMANA) 243857157 Fort Liberty BILL 11/30/2023 12/01/2023 Ineligible Policy $19.80
30666 Spear, Elise D TRICARE EAST (HUMANA) 622485904 Fort Liberty BILL 11/30/2023 12/01/2023 Ineligible Policy $19.80
31385 Ortiz, Priscila TRICARE EAST (HUMANA) 668229364 Fort Campbell KY BILL 11/30/2023 12/01/2023 Ineligible Policy $19.80
31442 Ortiz, Priscila TRICARE EAST (HUMANA) 668229364 Fort Campbell KY 6 MTH RESUPPLY 11/30/2023 02/02/2024 Ineligible Policy $19.80
31409 Campbell, Layia A TRICARE EAST (HUMANA) 243992413 Fort Campbell KY BILL 11/30/2023 12/01/2023 Ineligible Policy $19.80
32174 Campbell, Layia A TRICARE EAST (HUMANA) 243992413 Fort Campbell KY 6 MTH RESUPPLY 11/30/2023 02/02/2024 Ineligible Policy $19.80
31415 MILLER, ANGELA M TRICARE EAST (HUMANA) 270663502 Chantilly VA BILL 11/30/2023 12/01/2023 Ineligible Policy $19.80
31429 HENZEN, EMILY TRICARE EAST (HUMANA) 385259144 Nellis AFB NV BILL-9/1 SEND 11/30/2023 12/01/2023 Ineligible Policy $19.80
RX TO EAST

31474 BONURA, ELIZA K TRICARE EAST (HUMANA) 576176982 Fort Belvoir VA BILL 11/30/2023 12/01/2023 Ineligible Policy $19.80
32183 BONURA, ELIZA K TRICARE EAST (HUMANA) 576176982 Fort Belvoir VA 6 MTH RESUPPLY 11/30/2023 02/02/2024 Ineligible Policy $13.20
31475 MARCHIAFAVA, KATIE B TRICARE EAST (HUMANA) 228616799 Fort Belvoir VA BILL 11/30/2023 12/01/2023 Ineligible Policy $19.80
32171 MARCHIAFAVA, KATIE B TRICARE EAST (HUMANA) 228616799 Fort Belvoir VA 6 MTH RESUPPLY 11/30/2023 02/02/2024 Ineligible Policy $118.80
31485 LI, DUONING TRICARE EAST (HUMANA) 640287204 Fort Stewart GA BILL 11/30/2023 12/01/2023 Ineligible Policy $19.80
32173 LI, DUONING TRICARE EAST (HUMANA) 640287204 Fort Stewart GA 11/30/2023 02/02/2024 Ineligible Policy $19.80
31510 BROWN, BREANNA L TRICARE EAST (HUMANA) 644183090 Fort Cavazos TX BILL 11/30/2023 12/01/2023 Ineligible Policy $19.80
32181 BROWN, BREANNA L TRICARE EAST (HUMANA) 644183090 Fort Cavazos TX 6 MTH RESUPPLY 11/30/2023 02/02/2024 Ineligible Policy $19.80
31514 LONG, ALLIE E TRICARE EAST (HUMANA) 245991445 Fort Cavazos TX BILL 11/30/2023 12/01/2023 Ineligible Policy $19.80
32175 LONG, ALLIE E TRICARE EAST (HUMANA) 245991445 Fort Cavazos TX 6 MTH RESUPPLY 11/30/2023 02/02/2024 Ineligible Policy $19.80
31622 Sola-Garcia, Natalie TRICARE EAST (HUMANA) 596567158 Fort Liberty BILL 11/30/2023 12/01/2023 Ineligible Policy $19.80
31623 Quiles Matias, Astrid TRICARE EAST (HUMANA) 596285839 Fort Liberty BILL 11/30/2023 12/01/2023 Ineligible Policy $19.80
32816 JOHNSON, MORGAN R TRICARE EAST (HUMANA) 252831749 Chantilly VA 11/30/2023 12/01/2023 Ineligible Policy $185.05
32878 JOHNSON, MORGAN R TRICARE EAST (HUMANA) 252831749 Chantilly VA BILL 11/30/2023 12/04/2023 Ineligible Policy $19.80
34026 Hamlin, Kelly L TRICARE EAST (HUMANA) 278743683 Fort Liberty 11/30/2023 12/01/2023 Ineligible Policy $369.95
34555 WILLIAMS-HARBAUGH, TRICARE EAST (HUMANA) 172707337 Chantilly VA BILL 11/30/2023 12/01/2023 Ineligible Policy $19.80
DESHANA M

34561 TYSON, MEGAN TRICARE EAST (HUMANA) 621268172 Fort Liberty BILL 11/30/2023 12/01/2023 Ineligible Policy $19.80
34631 TYSON, MEGAN TRICARE EAST (HUMANA) 621268172 Fort Liberty 11/30/2023 12/19/2023 Ineligible Policy $14.34
34632 TYSON, MEGAN TRICARE EAST (HUMANA) 621268172 Fort Liberty 6 MTH RESUPPLY 11/30/2023 05/01/2024 Ineligible Policy $19.80
34562 SANCHEZ, LESLIE TRICARE EAST (HUMANA) 341880988 Fort Liberty BILL 11/30/2023 12/01/2023 Ineligible Policy $19.80
34614 SANCHEZ, LESLIE TRICARE EAST (HUMANA) 341880988 Fort Liberty 11/30/2023 12/01/2023 Ineligible Policy $125.53
34615 SANCHEZ, LESLIE TRICARE EAST (HUMANA) 341880988 Fort Liberty 6 MTH RESUPPLY 11/30/2023 05/01/2024 Ineligible Policy $19.80
34575 BRISCO, Kotrecia Jeanette TRICARE EAST (HUMANA) 632729304 Fort Liberty BILL 11/30/2023 12/01/2023 Ineligible Policy $19.80
34507 MENG, SAMANTHA A TRICARE EAST (HUMANA) 296964476 Chantilly VA 11/30/2023 12/18/2023 Ineligible Policy $14.34
34580 MENG, SAMANTHA A TRICARE EAST (HUMANA) 296964476 Chantilly VA BILL 11/30/2023 12/01/2023 Ineligible Policy $19.80
34585 FORDJOUR, LINDA TRICARE EAST (HUMANA) 649084788 Fort Cavazos TX BILL 11/30/2023 12/01/2023 Ineligible Policy $19.80

Printed On 11/30/2023 Page 2 of 3

 Sales Order Template Stops
34634 FORDJOUR, LINDA TRICARE EAST (HUMANA) 649084788 Fort Cavazos TX 11/30/2023 12/01/2023 Ineligible Policy $14.34
34645 FORDJOUR, LINDA TRICARE EAST (HUMANA) 649084788 Fort Cavazos TX 6 MTH RESUPPLY 11/30/2023 10/01/2024 Ineligible Policy $19.80
34595 NEGRON TORRES, TIFFANY TRICARE WEST (HEALTH 01658060201 Fort Bliss TX BILL 11/30/2023 12/01/2023 Ineligible Policy $19.80
MICHELLE NET)

34596 MEJIA-JUAREZ, LESLYE A TRICARE WEST (HEALTH 630743074 Fort Bliss TX BILL 11/30/2023 12/01/2023 Ineligible Policy $19.80
NET)

28276 Yaguissagou, Dikpagoh M TRICARE EAST (HUMANA) 328674824 Fort Campbell KY 6 MTH RESUPPLY 11/30/2023 04/29/2024 Ineligible Policy $18.00
34597 Yaguissagou, Dikpagoh M TRICARE EAST (HUMANA) 328674824 Fort Campbell KY BILL 11/30/2023 12/01/2023 Ineligible Policy $19.80
34569 Molina Buck, Jennifer TRICARE EAST (HUMANA) 061925666 Fort Campbell KY 11/30/2023 12/15/2023 Ineligible Policy $125.53
34599 Molina Buck, Jennifer TRICARE EAST (HUMANA) 061925666 Fort Campbell KY BILL 11/30/2023 12/01/2023 Ineligible Policy $19.80
34684 Molina Buck, Jennifer TRICARE EAST (HUMANA) 061925666 Fort Campbell KY 6 MTH RESUPPLY 11/30/2023 05/01/2024 Ineligible Policy $19.80
34565 Jones, Caterina TRICARE EAST (HUMANA) 010748946 Fort Campbell KY 11/30/2023 01/19/2024 Ineligible Policy $14.34
34600 Jones, Caterina TRICARE EAST (HUMANA) 010748946 Fort Campbell KY BILL 11/30/2023 12/01/2023 Ineligible Policy $19.80
34683 Jones, Caterina TRICARE EAST (HUMANA) 010748946 Fort Campbell KY 6 MTH RESUPPLY 11/30/2023 05/01/2024 Ineligible Policy $19.80
34603 HERNANDEZ, JACQUILINE TRICARE EAST (HUMANA) 608605921 Fort Cavazos TX BILL 11/30/2023 12/01/2023 Ineligible Policy $19.80
34687 HERNANDEZ, JACQUILINE TRICARE EAST (HUMANA) 608605921 Fort Cavazos TX 11/30/2023 01/11/2024 Ineligible Policy $125.53
34688 HERNANDEZ, JACQUILINE TRICARE EAST (HUMANA) 608605921 Fort Cavazos TX 6 MTH RESUPPLY 11/30/2023 05/01/2024 Ineligible Policy $19.80
34617 GRAHAM, RAVEN TRICARE EAST (HUMANA) 620278876 Fort Belvoir VA 11/30/2023 12/01/2023 Ineligible Policy $14.34
34618 GRAHAM, RAVEN TRICARE EAST (HUMANA) 620278876 Fort Belvoir VA 6 MTH RESUPPLY 11/30/2023 05/01/2024 Ineligible Policy $19.80
34747 GRAHAM, RAVEN TRICARE EAST (HUMANA) 620278876 Fort Belvoir VA BILL 11/30/2023 12/01/2023 Ineligible Policy $19.80
34587 Herrell, Shiann TRICARE EAST (HUMANA) 643624418 Fort Campbell KY 11/30/2023 01/19/2024 Ineligible Policy $125.53
34622 Herrell, Shiann TRICARE EAST (HUMANA) 643624418 Fort Campbell KY BILL 11/30/2023 12/01/2023 Ineligible Policy $19.80
34654 Herrell, Shiann TRICARE EAST (HUMANA) 643624418 Fort Campbell KY 6 MTH RESUPPLY 11/30/2023 05/01/2024 Ineligible Policy $19.80
34612 BAYSINGER, MACAYLA TY TRICARE EAST (HUMANA) 513196714 Fort Cavazos TX 11/30/2023 01/19/2024 Ineligible Policy $125.53
34613 BAYSINGER, MACAYLA TY TRICARE EAST (HUMANA) 513196714 Fort Cavazos TX 6 MTH RESUPPLY 11/30/2023 05/01/2024 Ineligible Policy $19.80
34626 BAYSINGER, MACAYLA TY TRICARE EAST (HUMANA) 513196714 Fort Cavazos TX BILL 11/30/2023 12/01/2023 Ineligible Policy $19.80
34629 SZYMANSKI, SVETLANA A TRICARE EAST (HUMANA) 01639337101 Fort Stewart GA BILL 11/30/2023 12/01/2023 Ineligible Policy $19.80
34675 SZYMANSKI, SVETLANA A TRICARE EAST (HUMANA) 01639337101 Fort Stewart GA 11/30/2023 12/19/2023 Ineligible Policy $14.34
34676 SZYMANSKI, SVETLANA A TRICARE EAST (HUMANA) 01639337101 Fort Stewart GA 6 MTH RESUPPLY 11/30/2023 05/01/2024 Ineligible Policy $19.80
34572 HICKS, EASTAN TRICARE EAST (HUMANA) 603388776 Fort Belvoir VA 6 MTH RESUPPLY 11/30/2023 01/31/2024 Ineligible Policy $19.80
34748 HICKS, EASTAN TRICARE EAST (HUMANA) 603388776 Fort Belvoir VA BILL 11/30/2023 12/01/2023 Ineligible Policy $19.80

Printed On 11/30/2023 Page 3 of 3