07/04/2024

Explanation of Benefits
Risk Carrier : Sarwa Life Insurance Policy Holder Name : KAYAN
Member : 50023237 52165616 Staff # : 405 Provider : Mahmoud Tarek El Reedy Pharmacy - Ebad El Rahman Hospital
Claim Number :
MCN : 73501102 Batch # : 0
Principal Name : WAEL MOHAMED
Name : WAEL MOHAMED
Date Of Birth : 1985

Transaction Date : 04/04/2024 Invoice Number : Physician : Default Doctor

Diagnosis : Unspecified diabetes mellitus without complications Approved by

Detailed Bill Med File : Cons. Fees : 0.00 EGP SSNBR : 84321497

Service Item Unit Price Type Qty Claimed Curr Total Claimed Qty Appr. Total Appr. Disc.

PHARMACY 1- DEGREASIAN 7 cap per strip Caps 1 34.500 Strip 9 EGP 310.500 9 310.500 37.260
GM 28 caps / 2 Caps per day
2- FORXIGA Tabs 10 MG 28 tabs / 1 Tabs 460.000 Box 1 EGP 460.000 1 460.000 27.600
per day
3- LANTUS (SOLOSTAR) Inj 100 IU/ml 174.000 Cart 2 EGP 348.000 2 348.000 20.880
1500 iu / 20 Inj per day
4- JANUMET Tabs 50/1000 mg 56 tabs / 2 444.000 Box 1 EGP 444.000 1 444.000 26.640
Tabs per day
5- LIPANTHYL SUPRA Tabs 160 mg 30 75.000 Box 1 EGP 75.000 1 75.000 9.000
tabs / 1 Tabs per day
6- LIPITOR Tabs 80 mg 14 tabs / 1 Tabs 179.000 Box 2 EGP 358.000 2 358.000 42.960
per day
7- NEUROTON Tabs 30 tabs / 1 Tabs per 61.500 Box 1 EGP 61.500 1 61.500 7.380
day

Summary Patient Share

Total Claimed 2,057.000 EGP Co-Insurance 0.000 EGP
Total Approved 2,057.000 EGP Exceeding Limitation 0.000 EGP
Discount 171.720 EGP Uncovered Items 0.000 EGP

Net Amount 1,885.280 EGP Total Patient Share 0.000 EGP

The claims will be subject to review and audit based on the Tariff, Discounts and Medical Necessity (Usual, Reasonable and Customary), on case by case basis. Thank You. Page 1 of 1