Records|

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Referral Number|Hub Order Transaction Number|Date of Referral Started|Referral
Source|Brand Name|Referred NDC Code|RX Number|Authorized refills|Primary Diagnosis
Code|Secondary Diagnosis Code|Tertiary Diagnosis Code|NPI # |DEA#|SPP Physician ID|
First Name|Middle Name|Last Name |Suffix|Physician Address1|Physician Address2|
Physician City|Physician State|Physician Zip|Physician Phone|Physician Fax|Primary
Payer BIN|Primary Payer PCN|Primary Group #|Primary Payer ID|Primary Payer Name|
Primary Payer Type |Primary Benefit Type|Primary Plan ID|Primary Plan Name|Primary
Plan Type|Primary Patient Out-of-Pocket amount|Primary Co-Pay amount|Primary Co-Pay
Type|Primary Deductible|Primary Max out of pocket|Primary Lifetime Max|Primary PA
Required|Primary PA Expiration Date|Secondary Payer BIN|Secondary Payer PCN|
Secondary Group #|Secondary Payer ID|Secondary Payer Name|Secondary Payer Type |
Secondary Benefit Type|Secondary Plan ID|Secondary Plan Name|Secondary Plan Type|
Patient Out-of-Pocket amount|Secondary Co-Pay amount|Secondary Co-Pay Type|
Secondary Deductible|Secondary Max out of pocket|Secondary Lifetime Max|Secondary
PA Required|Secondary PA Expiration Date|SPP Patient ID |HUB Identifier|HIPAA
Consent|Patient State|Patient YOB|Patient Gender |Current Referral Status |Status
Date|Status Reason Code |Pharmacy Name|Pharmacy Location Name|Location DEA|Location
NPI Number|Location NCPDP Number|Record ID|Restatement Flag|Data 2000 DEA #|CFR
Part 2 Consent|Comment 3|Comment 4|Comment 5|Comment 6|Comment 7|Comment 8|Comment
9|Comment 10|Comment 11|Comment 12|Comment 13|Comment 14|Comment 15|Comment 16|
Comment 17|Comment 18|Comment 19|Comment 20
4078311739||20171015|PRESCRIBER|SUBOXONE|00124-9612-02|348059|12|A001|M06.9|M06.9|
1124036371|BL1993218|19514|HUGO |C|LUTTON||7383 E TANQUE VERDE RD
|STE 253|LEXINGTON |KY|40504|7733576840|8668747504|610097|VPC3|
TENNCARE||CENTENE|INTEGRATED PBM|MEDICAL|178|Illinicare||68.09|68.09|% |1399|1399|
1399|N|20170914|610097|VPC3|TENNCARE||CENTENE|INTEGRATED PBM|MEDICAL|178|
Illinicare||68.09|68.09|% |1399|1399|1399|N|20170914|3256504682FL|523630|N|OH|
1986|F|ACTIVE|20171022|A01|Diplomat|HOUSTON|FF2412752|1962406850|4544424|
1220806003_2064090006_20160509154203|N|BL1993218|N|Indivior1|Indivior2|Indivior3|
Indivior4|Indivior5|Indivior6|Indivior7|Indivior8|Indivior9|Indivior10|Indivior11|
Indivior12|Indivior13|Indivior14|Indivior15|Indivior16|Indivior17|Indivior18
2974476766||20171015|PRESCRIBER|SUBOXONE|00124-9612-02|348059|12|A001|M06.9|M06.9|
1124036371|BL1993218|19514|HUGO |C|LUTTON||7383 E TANQUE VERDE RD
|STE 253|LEXINGTON |KY|40504|7733576840|8668747504|610097|VPC3|
TENNCARE||CENTENE|INTEGRATED PBM|MEDICAL|178|Illinicare||68.09|68.09|% |1399|1399|
1399|N|20170914|610097|VPC3|TENNCARE||CENTENE|INTEGRATED PBM|MEDICAL|178|
Illinicare||68.09|68.09|% |1399|1399|1399|N|20170914|3256504682FL|523630|N|OH|
1986|F|DISCONTINUED|20171022|DC30|Diplomat|HOUSTON|FF2412752|1962406850|4544424|
1220806003_2064090006_20160509154203|N|BL1993218|N|Indivior1|Indivior2|Indivior3|
Indivior4|Indivior5|Indivior6|Indivior7|Indivior8|Indivior9|Indivior10|Indivior11|
Indivior12|Indivior13|Indivior14|Indivior15|Indivior16|Indivior17|Indivior18