<PBMClaimRecord> <AHFS>281604<AHFS>
<AWPCost>667.1300<AWPCost>
<ActionFlag i:nil="true"/>
<AddDateTime>2008-04-01T01:01:00<AddDateTime>
<AddHXUserid i:nil="true"/>
<AltMemberID i:nil="true"/>
<AppliedMABAmt>0.0000<AppliedMABAmt>
<AppliedOOPAmt>0.0000<AppliedOOPAmt>
<BnftPlan i:nil="true"/>
<COB>0<COB>
<COB_Amt>0.0000<COB_Amt>
<CheckNum>0000000<CheckNum>
<CheckNum2 i:nil="true"/>
<Coinsurance_Amt>0.0000<Coinsurance_Amt>
<Comment i:nil="true"/>
<CompoundCode i:nil="true"/>
<DAW>0<DAW>
<DEACode>0<DEACode>
<DX1 i:nil="true"/>
<DX2 i:nil="true"/>
<DX3 i:nil="true"/>
<DateFilled>2011-03-15T00:00:00<DateFilled>
<DatePaid>2011-03-15T00:00:00<DatePaid>
<DateSubmitted>2011-03-15T00:00:00<DateSubmitted>
<DaysSupply>90<DaysSupply>
<Ded>0.0000<Ded>
<DepAltMemberID i:nil="true"/>
<DepNum>54687/4115<DepNum>
<DepSSN i:nil="true"/>
<DispensingFee>2.2500<DispensingFee>
<DrugFormPenAmt>0.0000<DrugFormPenAmt>
<DrugStr i:nil="true"/>
<EERespOn>0.0000<EERespOn>
<EE_Addr2 i:nil="true"/>
<EE_Address i:nil="true"/>
<EE_City i:nil="true"/>
<EE_St i:nil="true"/>
<EE_Zip i:nil="true"/>
<EmployeeFirstName i:nil="true"/>
<EmployeeLastName i:nil="true"/>
<EmployeeSSN>*********<EmployeeSSN>
<ExcessMABAmt>0.0000<ExcessMABAmt>
<ExcessOOPAmt>0.0000<ExcessOOPAmt>
<GenericCode i:nil="true"/>
<GroupNum>pmed<GroupNum>
<GrpDAWPenDiff>0.0000<GrpDAWPenDiff>
<GrpDueAmt>0.0000<GrpDueAmt>
<GrpExcessClaimsAmt>0.0000<GrpExcessClaimsAmt>
<Inelig>0.0000<Inelig>
<IngredientCost>29.0000<IngredientCost>
<LabelName>FLUOXETINE CAP 10MG <LabelName>
<LastChange i:nil="true"/>
<Location i:nil="true"/>
<MACFlag i:nil="true"/>
<MACPrice>0.0000<MACPrice>
<MaintDrugFlag>1<MaintDrugFlag>
<MaxRefill>0<MaxRefill>
<MemDAWPenAmt>0.0000<MemDAWPenAmt>
<MemDAWPenDiff>0.0000<MemDAWPenDiff>
<MemExcessClaimsAmt>0.0000<MemExcessClaimsAmt>
<MemberId>86686686600<MemberId>
<MetricUnits>270<MetricUnits>
<ModDateTime i:nil="true"/>
<ModHXUserid i:nil="true"/>
<NDCNumber i:nil="true"/>
<NatProvID i:nil="true"/>
<PBMClaimId>6879554-7e7d-4d93-a477-8c5d4201517b<PBMClaimId>
<PCPTIN> <PCPTIN>
<PPOFlag/>
<PPOName i:nil="true"/>
<PPONumber i:nil="true"/>
<PTDOB>1963-05-28T00:00:00<PTDOB>
<PTName>Andy Ananalgam<PTName>
<PTSex>M<PTSex>
<Payor>Eaglewood Administrators<Payor>
<PayorOrgId>752375c3-7488-45a9-9ff7-db4282d6c460<PayorOrgId>
<PayorPaid>11.2500<PayorPaid>
<PharmDAWPenDiff>0.0000<PharmDAWPenDiff>
<PharmExcessClaimsAmt>0.0000<PharmExcessClaimsAmt>
<PharmId>BUEHLR<PharmId>
<PharmName>BUEHLER'S PHARMACY <PharmName>
<PharmNetPenAmt>0.0000<PharmNetPenAmt>
<Pharm_Addr2 i:nil="true"/>
<Pharm_Address i:nil="true"/>
<Pharm_City i:nil="true"/>
<Pharm_St i:nil="true"/>
<Pharm_Zip i:nil="true"/>
<PharmacyChain>658 <PharmacyChain>
<PrescribeNetPenAmt>0.0000<PrescribeNetPenAmt>
<PrescribedDate i:nil="true"/>
<PrescriberAddr2 i:nil="true"/>
<PrescriberAddress i:nil="true"/>
<PrescriberCity i:nil="true"/>
<PrescriberName i:nil="true"/>
<PrescriberSpecCode i:nil="true"/>
<PrescriberSpecDesc i:nil="true"/>
<PrescriberTINSuffix i:nil="true"/>
<PrescriberTaxId>65433aad388<PrescriberTaxId>
<Prescriber_St i:nil="true"/>
<Prescriber_Zip i:nil="true"/>
<PriceScheduleType>5<PriceScheduleType>
<ProdID i:nil="true"/>
<ProviderComment i:nil="true"/>
<RXClarificationCode i:nil="true"/>
<RXNum>04-2008-pmed<RXNum>
<RXOrigin>0<RXOrigin>
<RefillCode>1<RefillCode>
<RejectCode1 i:nil="true"/>
<RejectCode2 i:nil="true"/>
<RejectCode3 i:nil="true"/>
<RejectCode4 i:nil="true"/>
<RejectCode5 i:nil="true"/>
<RejectCode6 i:nil="true"/>
<RelCode i:nil="true"/>
<RxType>3<RxType>
<SalesTax>0.0000<SalesTax>
<SavDisc>0.0000<SavDisc>
<TotalChg>31.2500<TotalChg>
<TotalMemAmt>0.0000<TotalMemAmt>
<TotalPenalty>0.0000<TotalPenalty>
<TotalPharmAmt>0.0000<TotalPharmAmt>
<TransStatus>1<TransStatus>
<TransType>1<TransType>
<UNC>121.3400<UNC>
<UserDefinedNumeric1 i:nil="true"/>
<UserDefinedNumeric2 i:nil="true"/>
<UserDefinedNumeric3 i:nil="true"/>
<UserDefinedText1 i:nil="true"/>
<UserDefinedText2 i:nil="true"/>
<UserDefinedText3 i:nil="true"/>
<ViewDateTime i:nil="true"/>
<checkPaidTo>BUEHLER'S PHARMACY <checkPaidTo>
<checkPaidTo2 i:nil="true"/>
<copay_Amt>20.0000<copay_Amt> <PBMClaimRecord> |
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