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Claim information
Fill date : PRIVATE 05/11/2018 Claim number : 1111111111111111Drug information
Drug name : PRIVATE LISINOPRIL TAB 5MG Rx : PRIVATE 000000004806 Quantity : PRIVATE 90.000 Prescriber : PRIVATE THEODORYPayment information
You paid*: $0.00 Plan paid : $19.71Product select amount : $0.00 Exceed max amount : $0.00 Sales tax : $0.00
*This prescription was processed through the Enhanced Savings Program (ESP), a program offered by your health plan that allows you to receive discounts on the out-of-pocket price for non-covered medications. Because it is a non-covered medication, it does not apply to your deductible or out-of-pocket maximum.
** A $0.00 manufacturer copay card was redeemed and applied to reduce your claim cost share.
This copay card amount was not applied to your deductible or out-of-pocket maximum.
This copay card amount was not applied to your deductible or out-of-pocket maximum.
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Disclamier: Prices on some of your medication(s) may vary based on your doctor's instructions or on the manufacturer's price provided to us at the time you place your order online or at your pharmacy.
