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Revised January, 2010 CONFIDENTIAL AND PROPRIETARY - page 15 / 31

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15 / 31

CONFIDENTIAL AND PROPRIETARY

  • 8.

    Sex - place an “X” in the appropriate box to identify patient’s sex.

  • 9.

    Relationship to Cardholder – place an “X” in the Cardholder, Child, Spouse, or other box as appropriate.

  • 10.

    Date Rx(s) Written - month, day, and year the prescription(s) was\were written (MMDDYYYY).

  • 11.

    Date Rx(s) Filled - month, day, and year the prescription(s) was\were filled (MMDDYYYY).

  • 12.

    Rx Number - prescription number consisting of up to seven digits.

  • 13.

    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.

  • 14.

    Metric Quantity - number of tablets, capsules, etc., dispensed.

    • a)

      When liquids are dispensed, use ml or cc and decimals if appropriate (i.e.,

      • 2.5)

        .

    • b)

      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.

    • c)

      Do not write the metric form being used (e.g., ml or cc) on the UCF.

  • 15.

    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.”

  • 16.

    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.

  • 17.

    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.

  • 18.

    DAW (dispense as written) – Standard NCPDP Codes are:

        • 0

          = 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

  • 19.

    Ingr. Cost - billed amount for the dispensed quantity of drug only ($$$.¢¢).

  • 20.

    Disp. Fee (optional) - professional fee charged for dispensing the drug ($$$.¢¢).

  • 21.

    Tax - appropriate city, county, and state tax, where applicable.

  • 22.

    Total price (required) - total of the ingredient cost, dispensing fee, and tax ($$$.¢¢), or the usual and customary retail, whichever is less.

  • 23.

    DED. Amt. (Optional) - copay amount collected ($$$.¢¢).

  • 24.

    Bal - The total billed amount ($$$.¢¢).

Walgreens Health Initiatives – Pharmacy Manual

15

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