CONFIDENTIAL AND PROPRIETARY
Sex - place an “X” in the appropriate box to identify patient’s sex.
Relationship to Cardholder – place an “X” in the Cardholder, Child, Spouse, or other box as appropriate.
Date Rx(s) Written - month, day, and year the prescription(s) was\were written (MMDDYYYY).
Date Rx(s) Filled - month, day, and year the prescription(s) was\were filled (MMDDYYYY).
Rx Number - prescription number consisting of up to seven digits.
NEW or REFILL - place an “N” in the box if this pertains to an original prescription, or “R” in the box if it is a refill.
Metric Quantity - number of tablets, capsules, etc., dispensed.
When liquids are dispensed, use ml or cc and decimals if appropriate (i.e.,
When original packages (ointments, drops, etc.) are dispensed, use metric units dispensed such as grams or cc. For example, Aristocort Cr ½ oz. should show “15” - referring to the number of grams.
Do not write the metric form being used (e.g., ml or cc) on the UCF.
Days Supply - number of days the medication will last the patient when taken according to directions. If the days supply is not applicable or not known, enter “1.”
National Drug Code - The national drug code for the drug being dispensed. If the drug is a compound, enter the NDC of the most expensive legend ingredient, and detail the compound on the back of each claim form. Include the NDC number of each ingredient in the compound.
Prescriber Identification - the prescriber’s ID number. A valid DEA number must be submitted for each claim. If the DEA number is not available, please provide the prescriber’s name.
DAW (dispense as written) – Standard NCPDP Codes are:
= No product selection indicated 1 = Substitution not allowed by prescriber 2 = Substitution allowed - patient requested product dispensed 3 = Substitution allowed - pharmacist selected product dispensed 4 = Substitution allowed - generic drug not in stock 5 = Substitution allowed - brand drug dispensed as a generic 6 = Override
7 = Substitution not allowed - brand drug mandated by law 8 = Substitution allowed - generic drug not available in marketplace 9 = Other
Ingr. Cost - billed amount for the dispensed quantity of drug only ($$$.¢¢).
Disp. Fee (optional) - professional fee charged for dispensing the drug ($$$.¢¢).
Tax - appropriate city, county, and state tax, where applicable.
Total price (required) - total of the ingredient cost, dispensing fee, and tax ($$$.¢¢), or the usual and customary retail, whichever is less.
DED. Amt. (Optional) - copay amount collected ($$$.¢¢).
Bal - The total billed amount ($$$.¢¢).
Walgreens Health Initiatives – Pharmacy Manual