PT.

(Persero) ASURANSI KESEHATAN INDONESIA

LAMPIRAN FORMULIR PENGAJUAN KLAIM
NAMA PPK : IFRS RSIA BAHAGIA

TINGKAT PELAYANAN : RJTL

NO FPK : 0342A060071831

No. Biaya
No. No Kartu Askes PISA R/N Tingkat Nama Obat
Pelayanan Resep Diajukan Disetujui

1 0002267863457 p N RJTL 00001 Amlodipin 10 mg Plab 3150,08 3150,08

N RJTL 00001 Glimepirid 3 mg Guar 8419,84 8419,84

N RJTL 00001 Simvastatin 10 mg Mers 3326,72 3326,72

2 0002267862939 p N RJTL 00002 Amlodipin 10 mg Plab 3150,08 3150,08

N RJTL 00002 Simvastatin 20 mg Kifa 7360 7360

N RJTL 00002 Spironolakton 25 mg Dexa 4254,72 4254,72

N RJTL 00002 Vitamin B12 (Sianokobalamin) 50 mcg Mari 1619,2 1619,2

3 0000129796839 P N RJTL 00083 Metformin HCl 500 mg Temp 6064,64 6064,64

N RJTL 00083 Nifedipin 10 mg Dexa 6758,4 6758,4

N RJTL 00083 Vitamin B1 (Thiamin HCl) 50 mg Noph 2561,28 2561,28

N RJTL 00083 Vitamin B12 (Sianokobalamin) 50 mcg Mari 1619,2 1619,2

N RJTL 00083 Vitamin B6 (Piridoksin HCl) 10 mg Kifa 4003,84 4003,84

4 0001851218908 P N RJTL 00087 Levemir Flexpen 100 UI/ml Beta 107100 107100

N RJTL 00087 Simvastatin 20 mg Kifa 7360 7360

5 0000127178785 p N RJTL 00088 Amlodipin 10 mg Plab 3150,08 3150,08

N RJTL 00088 Simvastatin 10 mg Mers 3326,72 3326,72

6 0000048009778 p N RJTL 00089 Kaptopril 12,5 mg Phap 3944,96 3944,96

7 0002178785979 p N RJTL 00090 Apidra Solostar 100 UI/ml Aven 328860 328860

8 0001069751845 p N RJTL 00091 Glimepirid 1 mg Hexp 5711,36 5711,36

9 0001825982774 P N RJTL 00092 Kaptopril 12,5 mg Phap 3944,96 3944,96

N RJTL 00092 Simvastatin 20 mg Kifa 7360 7360

10 0000129389038 P N RJTL 00093 Amlodipin 10 mg Plab 3150,08 3150,08

N RJTL 00093 Simvastatin 20 mg Kifa 7360 7360

N RJTL 00093 Valsartan 80 mg SK20 28174,08 28174,08

11 0002292075562 p N RJTL 00094 Metformin HCl 500 mg Temp 3032,32 3032,32

N RJTL 00094 Vitamin B12 (Sianokobalamin) 50 mcg Mari 1619,2 1619,2

12 0000127180293 p N RJTL 00095 Amlodipin 5 mg Temp 2649,6 2649,6

N RJTL 00095 Simvastatin 20 mg Kifa 7360 7360

N RJTL 00095 Vitamin B12 (Sianokobalamin) 50 mcg Mari 1619,2 1619,2

 PT.(Persero) ASURANSI KESEHATAN INDONESIA
LAMPIRAN FORMULIR PENGAJUAN KLAIM
NAMA PPK : IFRS RSIA BAHAGIA

TINGKAT PELAYANAN : RJTL

NO FPK : 0342A060071831

No. Biaya
No. No Kartu Askes PISA R/N Tingkat Nama Obat
Pelayanan Resep Diajukan Disetujui
N RJTL Vitamin B12 (Sianokobalamin) 50 mcg Mari

13 0000126657483 p N RJTL 00096 Simvastatin 20 mg Kifa 7360 7360

N RJTL 00096 Vitamin B12 (Sianokobalamin) 50 mcg Mari 1619,2 1619,2

14 0000152939496 p N RJTL 00097 Atorvastatin 20 mg Nove 35298,56 35298,56

N RJTL 00097 Glimepirid 2 mg Guar 6800,64 6800,64

N RJTL 00097 Metformin HCl 500 mg Temp 3032,32 3032,32

15 0000126735107 P N RJTL 00098 Amlodipin 10 mg Plab 3150,08 3150,08

N RJTL 00098 Valsartan 160 mg SK20 44866,56 44866,56

16 0000127173879 p N RJTL 00099 Amlodipin 10 mg Plab 3150,08 3150,08

N RJTL 00099 Glimepirid 3 mg Guar 8419,84 8419,84

N RJTL 00099 Simvastatin 10 mg Mers 3326,72 3326,72

N RJTL 00099 Vitamin B12 (Sianokobalamin) 50 mcg Mari 1619,2 1619,2

17 0001285719006 p N RJTL 00100 Atorvastatin 20 mg Nove 35298,56 35298,56

N RJTL 00100 Metformin HCl 500 mg Temp 6064,64 6064,64

N RJTL 00100 Vitamin B12 (Sianokobalamin) 50 mcg Mari 1619,2 1619,2

18 0000130342173 p N RJTL 00101 Metilprednisolon 4 mg Mole 9715,2 9715,2

N RJTL 00101 Simvastatin 10 mg Mers 3326,72 3326,72

19 0001555354383 p N RJTL 00102 Amlodipin 10 mg Plab 3150,08 3150,08

20 0000127156296 p N RJTL 00103 Amlodipin 10 mg Plab 3150,08 3150,08

N RJTL 00103 Kaptopril 25 mg Land 5063,68 5063,68

21 0001315393446 p N RJTL 00104 Amlodipin 5 mg Temp 2649,6 2649,6

N RJTL 00104 Atorvastatin 20 mg Nove 46041,6 46041,6

N RJTL 00104 Glimepirid 4 mg Guar 8743,68 8743,68

N RJTL 00104 Vitamin B12 (Sianokobalamin) 50 mcg Mari 1619,2 1619,2

22 0001107953954 P N RJTL 00105 Klopidogrel 75 mg Dexa 52962,56 52962,56

N RJTL 00105 Lisinopril 10 mg Dexa 10510,08 10510,08

N RJTL 00105 Simvastatin 20 mg Kifa 7360 7360

23 0001105583185 P N RJTL 00106 Amlodipin 10 mg Plab 3150,08 3150,08

N RJTL 00106 Bisoprolol 5 mg Hexp 8773,12 8773,12

 PT.(Persero) ASURANSI KESEHATAN INDONESIA
LAMPIRAN FORMULIR PENGAJUAN KLAIM
NAMA PPK : IFRS RSIA BAHAGIA

TINGKAT PELAYANAN : RJTL

NO FPK : 0342A060071831

No. Biaya
No. No Kartu Askes PISA R/N Tingkat Nama Obat
Pelayanan Resep Diajukan Disetujui

N RJTL 00106 Harnal Ocas 0.4 0,4 mg Comb 173696 173696

24 0001477972967 P N RJTL 00107 Harnal Ocas 0.4 0,4 mg Comb 173696 173696

25 0002196769803 P N RJTL 00108 Amlodipin 10 mg Plab 3150,08 3150,08

N RJTL 00108 Simvastatin 20 mg Kifa 7360 7360

N RJTL 00108 Vitamin B12 (Sianokobalamin) 50 mcg Mari 1619,2 1619,2

26 0002306729553 P N RJTL 00110 Alopurinol 100 mg Noph 3444,48 3444,48

N RJTL 00110 Kaptopril 25 mg Land 5063,68 5063,68

27 0000125506787 P N RJTL 00111 Bisoprolol 5 mg Hexp 8773,12 8773,12

N RJTL 00111 Farsorbid 10 10 mg Prat 5829,12 5829,12

N RJTL 00111 Glimepirid 1 mg Hexp 5711,36 5711,36

N RJTL 00111 Levemir Flexpen 100 UI/ml Beta 214200 214200

N RJTL 00111 Metformin HCl 500 mg Temp 9096,96 9096,96

28 0000125505382 P N RJTL 00112 Amlodipin 5 mg Temp 2649,6 2649,6

N RJTL 00112 Klopidogrel 75 mg Dexa 52962,56 52962,56

N RJTL 00112 Valsartan 80 mg SK20 28174,08 28174,08

29 0000127184411 P N RJTL 00113 Glibenklamide 5 mg SK20 5416,96 5416,96

N RJTL 00113 Metformin HCl 500 mg Temp 9096,96 9096,96

N RJTL 00113 Simvastatin 20 mg Kifa 7360 7360

N RJTL 00113 Vitamin B12 (Sianokobalamin) 50 mcg Mari 1619,2 1619,2

30 0001867066378 P N RJTL 00114 Apidra Solostar 100 UI/ml Aven 219240 219240

N RJTL 00114 Glimepirid 3 mg Guar 8419,84 8419,84

N RJTL 00114 Levemir Flexpen 100 UI/ml Beta 107100 107100

31 0000126812474 P N RJTL 00115 Amlodipin 10 mg Plab 3150,08 3150,08

N RJTL 00115 Atorvastatin 20 mg Nove 35298,56 35298,56

N RJTL 00115 Glimepirid 3 mg Guar 8419,84 8419,84

N RJTL 00115 Vitamin B12 (Sianokobalamin) 50 mcg Mari 1619,2 1619,2

32 0001272594802 P N RJTL 00116 Amlodipin 10 mg Plab 3150,08 3150,08

33 0000158022674 P N RJTL 00117 Alopurinol 100 mg Noph 3444,48 3444,48

 PT.(Persero) ASURANSI KESEHATAN INDONESIA
LAMPIRAN FORMULIR PENGAJUAN KLAIM
NAMA PPK : IFRS RSIA BAHAGIA

TINGKAT PELAYANAN : RJTL

NO FPK : 0342A060071831

No. Biaya
No. No Kartu Askes PISA R/N Tingkat Nama Obat
Pelayanan Resep Diajukan Disetujui

N RJTL 00117 Atorvastatin 20 mg Nove 35298,56 35298,56

N RJTL 00117 Glimepirid 1 mg Hexp 5711,36 5711,36

N RJTL 00117 Valsartan 80 mg SK20 28174,08 28174,08

N RJTL 00117 Vitamin B12 (Sianokobalamin) 50 mcg Mari 1619,2 1619,2

34 0000130553381 P N RJTL 00118 Amlodipin 10 mg Plab 3150,08 3150,08

N RJTL 00118 Atorvastatin 20 mg Nove 35298,56 35298,56

N RJTL 00118 Valsartan 80 mg SK20 28174,08 28174,08

N RJTL 00118 Vitamin B12 (Sianokobalamin) 50 mcg Mari 1619,2 1619,2

35 0001421161986 P N RJTL 00119 Amlodipin 10 mg Plab 3150,08 3150,08

N RJTL 00119 Glimepirid 3 mg Guar 8419,84 8419,84

N RJTL 00119 Lanzoprazol 30 mg Nufa 10598,4 10598,4

N RJTL 00119 Spironolakton 25 mg Dexa 8154,88 8154,88

36 0000945527354 p N RJTL 00120 Etambutol 500 mg Bern 31971,84 31971,84

N RJTL 00120 Pirazinamid 500 mg Holi 14013,44 14013,44

37 0001794905289 P N RJTL 00121 Amlodipin 10 mg Plab 3150,08 3150,08

N RJTL 00121 Lisinopril 5 mg Dexa 8655,36 8655,36

N RJTL 00121 Simvastatin 20 mg Kifa 7360 7360

38 0001482415121 p N RJTL 00122 Amlodipin 10 mg Plab 3150,08 3150,08

N RJTL 00122 Atorvastatin 20 mg Nove 35298,56 35298,56

39 0000127059175 P N RJTL 00123 Amlodipin 10 mg Plab 3150,08 3150,08

N RJTL 00123 Valsartan 80 mg SK20 28174,08 28174,08

40 0000127187019 P N RJTL 00124 Lanzoprazol 30 mg Nufa 10598,4 10598,4

41 0000127085488 P N RJTL 00125 Amlodipin 10 mg Plab 3150,08 3150,08

N RJTL 00125 Spironolakton 25 mg Dexa 8154,88 8154,88

N RJTL 00125 Valsartan 80 mg SK20 28174,08 28174,08

42 0000976534648 P N RJTL 00126 Alopurinol 100 mg Noph 4492,8 4492,8

N RJTL 00126 Amlodipin 10 mg Plab 3150,08 3150,08

N RJTL 00126 Simvastatin 10 mg Mers 3326,72 3326,72

 PT.(Persero) ASURANSI KESEHATAN INDONESIA
LAMPIRAN FORMULIR PENGAJUAN KLAIM
NAMA PPK : IFRS RSIA BAHAGIA

TINGKAT PELAYANAN : RJTL

NO FPK : 0342A060071831

No. Biaya
No. No Kartu Askes PISA R/N Tingkat Nama Obat
Pelayanan Resep Diajukan Disetujui

N RJTL 00126 Spironolakton 25 mg Dexa 8154,88 8154,88

43 0000126982179 P N RJTL 00083 Apidra Solostar 100 UI/ml Aven 328860 328860

N RJTL 00083 Levemir Flexpen 100 UI/ml Beta 107100 107100

N RJTL 00083 Spironolakton 25 mg Dexa 8154,88 8154,88

N RJTL 00083 Valsartan 80 mg SK20 28174,08 28174,08

44 0001958557656 P N RJTL 00084 Amlodipin 5 mg Temp 2649,6 2649,6

N RJTL 00084 Vitamin B1 (Thiamin HCl) 50 mg Noph 2561,28 2561,28

N RJTL 00084 Vitamin B12 (Sianokobalamin) 50 mcg Mari 1619,2 1619,2

N RJTL 00084 Vitamin B6 (Piridoksin HCl) 10 mg Kifa 4003,84 4003,84

45 0000127341369 P N RJTL 00085 Apidra Solostar 100 UI/ml Aven 328860 328860

N RJTL 00085 Glimepirid 3 mg Guar 8419,84 8419,84

N RJTL 00085 Levemir Flexpen 100 UI/ml Beta 107100 107100

N RJTL 00085 Vitamin B12 (Sianokobalamin) 50 mcg Mari 1619,2 1619,2

46 0001886699114 P N RJTL 00086 Amlodipin 10 mg Plab 3150,08 3150,08

N RJTL 00086 Simvastatin 10 mg Mers 3326,72 3326,72

N RJTL 00086 Vitamin B12 (Sianokobalamin) 50 mcg Mari 1619,2 1619,2

47 0001095737376 P N RJTL 00087 Amlodipin 10 mg Plab 3150,08 3150,08

N RJTL 00087 Vitamin B12 (Sianokobalamin) 50 mcg Mari 1619,2 1619,2

48 0001312088523 P N RJTL 00088 Amlodipin 5 mg Temp 2649,6 2649,6

N RJTL 00088 Simvastatin 10 mg Mers 3326,72 3326,72

N RJTL 00088 Vitamin B12 (Sianokobalamin) 50 mcg Mari 1619,2 1619,2

49 0000201315914 P N RJTL 00130 Glikuidon 30 mg Dexa 35592,96 35592,96

50 0001276934668 P N RJTL 00132 Lisinopril 10 mg Dexa 3198,72 3198,72

N RJTL 00132 Vitamin B Kompleks komb Kifa 3886,08 3886,08

51 0002170379283 P N RJTL 00133 Amlodipin 5 mg Temp 806,4 806,4

N RJTL 00133 Farsorbid 10 10 mg Prat 5829,12 5829,12

N RJTL 00133 Lisinopril 10 mg Dexa 3198,72 3198,72

N RJTL 00133 Simvastatin 20 mg Kifa 2240 2240

 PT.(Persero) ASURANSI KESEHATAN INDONESIA
LAMPIRAN FORMULIR PENGAJUAN KLAIM
NAMA PPK : IFRS RSIA BAHAGIA

TINGKAT PELAYANAN : RJTL

NO FPK : 0342A060071831

No. Biaya
No. No Kartu Askes PISA R/N Tingkat Nama Obat
Pelayanan Resep Diajukan Disetujui

N RJTL 00133 Spironolakton 25 mg Dexa 2481,92 2481,92

52 0001316783024 P N RJTL 00134 Amlodipin 5 mg Temp 2649,6 2649,6

N RJTL 00134 Spironolakton 25 mg Dexa 8154,88 8154,88

N RJTL 00134 Valsartan 80 mg SK20 28174,08 28174,08

53 0000927674289 P N RJTL 00135 Levemir Flexpen 100 UI/ml Beta 107100 107100

54 0000127360697 P N RJTL 00136 Metformin HCl 500 mg Temp 8833,28 8833,28

N RJTL 00136 Simvastatin 20 mg Kifa 7360 7360

N RJTL 00136 Valsartan 80 mg SK20 28174,08 28174,08

55 0001104391383 P N RJTL 00137 Amlodipin 10 mg Plab 958,72 958,72

N RJTL 00137 Glimepirid 1 mg Hexp 5711,36 5711,36

56 0001476386425 P N RJTL 00138 Levemir Flexpen 100 UI/ml Beta 107100 107100

N RJTL 00138 Novorapid Flexpen 100 IU/ml Beta 328860 328860

N RJTL 00138 Vitamin B1 (Thiamin HCl) 50 mg Noph 2561,28 2561,28

N RJTL 00138 Vitamin B12 (Sianokobalamin) 50 mcg Mari 1619,2 1619,2

N RJTL 00138 Vitamin B6 (Piridoksin HCl) 10 mg Kifa 4003,84 4003,84

57 0000127332674 P N RJTL 00139 Amlodipin 5 mg Temp 2649,6 2649,6

N RJTL 00139 Simvastatin 10 mg Mers 3326,72 3326,72

N RJTL 00139 Spironolakton 25 mg Dexa 8154,88 8154,88

58 0002033579169 P N RJTL 00140 Furosemid 40 mg Samp 2472,96 2472,96

N RJTL 00140 Spironolakton 25 mg Dexa 8154,88 8154,88

N RJTL 00140 Valsartan 80 mg SK20 28174,08 28174,08

59 0001079547478 P N RJTL 00141 Alopurinol 100 mg Noph 3444,48 3444,48

N RJTL 00141 Atorvastatin 20 mg Nove 35298,56 35298,56

N RJTL 00141 Glimepirid 4 mg Guar 8743,68 8743,68

N RJTL 00141 Metformin HCl 500 mg Temp 9096,96 9096,96

60 0000127031308 P N RJTL 00142 Glimepirid 2 mg Guar 6800,64 6800,64

N RJTL 00142 Simvastatin 20 mg Kifa 2240 2240

N RJTL 00142 Vitamin B12 (Sianokobalamin) 50 mcg Mari 492,8 492,8

 PT.(Persero) ASURANSI KESEHATAN INDONESIA
LAMPIRAN FORMULIR PENGAJUAN KLAIM
NAMA PPK : IFRS RSIA BAHAGIA

TINGKAT PELAYANAN : RJTL

NO FPK : 0342A060071831

No. Biaya
No. No Kartu Askes PISA R/N Tingkat Nama Obat
Pelayanan Resep Diajukan Disetujui

61 0001316784205 P N RJTL 00143 Glimepirid 1 mg Hexp 5711,36 5711,36

N RJTL 00143 Metformin HCl 500 mg Temp 9096,96 9096,96

62 0001266857177 P N RJTL 00144 Amlodipin 10 mg Plab 3150,08 3150,08

N RJTL 00144 Vitamin B1 (Thiamin HCl) 50 mg Noph 2561,28 2561,28

N RJTL 00144 Vitamin B12 (Sianokobalamin) 50 mcg Mari 1619,2 1619,2

N RJTL 00144 Vitamin B6 (Piridoksin HCl) 10 mg Kifa 4003,84 4003,84

63 0000127075195 P N RJTL 00145 Amlodipin 10 mg Plab 3150,08 3150,08

N RJTL 00145 Levemir Flexpen 100 UI/ml Beta 107100 107100

N RJTL 00145 Novorapid Flexpen 100 IU/ml Beta 438480 438480

N RJTL 00145 Valsartan 80 mg SK20 14087,04 14087,04

64 0002140224445 P N RJTL 00146 Amlodipin 10 mg Plab 3150,08 3150,08

N RJTL 00146 Farsorbid 10 10 mg Prat 11658,24 11658,24

N RJTL 00146 Irbesartan 300 mg Infa 24405,76 24405,76

N RJTL 00146 Klopidogrel 75 mg Dexa 52962,56 52962,56

N RJTL 00146 Metformin HCl 500 mg Temp 6064,64 6064,64

65 0001555332107 P N RJTL 00147 Valsartan 80 mg SK20 28174,08 28174,08

66 0000129389038 P N RJTL 00148 Atorvastatin 20 mg Nove 35298,56 35298,56

N RJTL 00148 Bisoprolol 5 mg Hexp 4386,56 4386,56

N RJTL 00148 Vitamin B12 (Sianokobalamin) 50 mcg Mari 1619,2 1619,2

67 0000126779793 P N RJTL 00149 Amlodipin 5 mg Temp 2649,6 2649,6

68 0000125394399 P N RJTL 00150 Amlodipin 5 mg Temp 2649,6 2649,6

N RJTL 00150 Vitamin B12 (Sianokobalamin) 50 mcg Mari 1619,2 1619,2

69 0000126684718 P N RJTL 00151 Glikuidon 30 mg Dexa 35592,96 35592,96

N RJTL 00151 Simvastatin 20 mg Kifa 7360 7360

N RJTL 00151 Vitamin B12 (Sianokobalamin) 50 mcg Mari 1619,2 1619,2

70 0000127165959 P N RJTL 00152 Amlodipin 5 mg Temp 2649,6 2649,6

N RJTL 00152 Simvastatin 20 mg Kifa 7360 7360

N RJTL 00152 Vitamin B12 (Sianokobalamin) 50 mcg Mari 1619,2 1619,2

 PT.(Persero) ASURANSI KESEHATAN INDONESIA
LAMPIRAN FORMULIR PENGAJUAN KLAIM
NAMA PPK : IFRS RSIA BAHAGIA

TINGKAT PELAYANAN : RJTL

NO FPK : 0342A060071831

No. Biaya
No. No Kartu Askes PISA R/N Tingkat Nama Obat
Pelayanan Resep Diajukan Disetujui

71 0001290581976 P N RJTL 00153 Amlodipin 5 mg Temp 2649,6 2649,6

N RJTL 00153 Glikuidon 30 mg Dexa 35592,96 35592,96

N RJTL 00153 Vitamin B1 (Thiamin HCl) 50 mg Noph 2561,28 2561,28

N RJTL 00153 Vitamin B12 (Sianokobalamin) 50 mcg Mari 1619,2 1619,2

N RJTL 00153 Vitamin B6 (Piridoksin HCl) 10 mg Kifa 4003,84 4003,84

72 0000945050073 P N RJTL 00154 Amlodipin 5 mg Temp 2649,6 2649,6

N RJTL 00154 Glikuidon 30 mg Dexa 35592,96 35592,96

N RJTL 00154 Lisinopril 5 mg Dexa 8655,36 8655,36

N RJTL 00154 Simvastatin 20 mg Kifa 7360 7360

73 0000127165948 P N RJTL 00155 Harnal D 0.2 0,2 mg Comb 209024 209024

N RJTL 00155 Valsartan 160 mg SK20 44866,56 44866,56

N RJTL 00155 Vitamin B12 (Sianokobalamin) 50 mcg Mari 1619,2 1619,2

74 0001283054095 P N RJTL 00156 Amlodipin 10 mg Plab 3150,08 3150,08

75 0001310740424 p N RJTL 00150 Novorapid Flexpen 100 IU/ml Beta 438480 438480

76 0000944591646 P N RJTL 00151 Bisoprolol 5 mg Hexp 4386,56 4386,56

N RJTL 00151 Vitamin B12 (Sianokobalamin) 50 mcg Mari 1619,2 1619,2

77 0001295183531 P N RJTL 00090 Glikuidon 30 mg Dexa 35592,96 35592,96

78 0000157064477 P N RJTL 00109 Amlodipin 10 mg Plab 3150,08 3150,08

N RJTL 00109 Glimepirid 1 mg Hexp 5711,36 5711,36

N RJTL 00109 Levemir Flexpen 100 UI/ml Beta 107100 107100

TOTAL 5.930.417,00 5.930.417,00

Mengetahui, Pimpinan MAKASSAR, 11 Juli 2018

Pembuat Laporan

dr. Yaser Ahmad Fananie Verifikator

Catt: Untuk per Obat Racikan ditambahkan embalase