‫‪Provider Claims Statements‬‬ ‫‪Page 1 of 7‬‬

‫)‪Pack# 9094(Network‬‬ ‫‪Date: 11/11/2021 5:59:38PM‬‬

‫)‪Sep claims 2021 SIC (Pharmacies‬‬
‫‪Provider:‬‬ ‫‪P1708-Isra Dauod Pharmacy‬‬ ‫‪Curr: SP-Syrian Pound‬‬
‫‪Payer:‬‬ ‫‪45 Syrian Insurance Company‬‬

‫‪Reference‬‬ ‫‪Patient‬‬ ‫‪Policy#‬‬ ‫‪Date‬‬ ‫‪Claimed Amnt‬‬ ‫‪Total Approved‬‬ ‫‪Payer Share‬‬

‫‪PM-8931883‬‬
‫محمد عيسى‬ ‫‪147385‬‬ ‫‪23992‬‬ ‫‪04/09/2021‬‬ ‫‪15,600.00‬‬ ‫‪15,600.00‬‬ ‫‪11,700.00‬‬

‫‪PM-8932459‬‬
‫أمل أحمد‬ ‫‪66964‬‬ ‫‪24567‬‬ ‫‪01/09/2021‬‬ ‫‪15,300.00‬‬ ‫‪15,300.00‬‬ ‫‪11,475.00‬‬

‫‪PM-8932923‬‬
‫دولت غنوم‬ ‫‪72551‬‬ ‫‪24567‬‬ ‫‪04/09/2021‬‬ ‫‪12,200.00‬‬ ‫‪12,200.00‬‬ ‫‪9,150.00‬‬

‫‪PM-8933050‬‬
‫رغداء أحمد‬ ‫‪74117‬‬ ‫‪24567‬‬ ‫‪04/09/2021‬‬ ‫‪18,200.00‬‬ ‫‪18,200.00‬‬ ‫‪13,650.00‬‬

‫‪PM-8933088‬‬
‫رندلين عيسى‬ ‫‪74665‬‬ ‫‪24567‬‬ ‫‪07/09/2021‬‬ ‫‪23,000.00‬‬ ‫‪23,000.00‬‬ ‫‪17,250.00‬‬

‫‪PM-8933468‬‬
‫سوسن احمد‬ ‫‪79383‬‬ ‫‪24567‬‬ ‫‪04/09/2021‬‬ ‫‪11,500.00‬‬ ‫‪11,500.00‬‬ ‫‪8,625.00‬‬

‫‪PM-8933522‬‬
‫شهناز دياب‬ ‫‪79926‬‬ ‫‪24567‬‬ ‫‪01/09/2021‬‬ ‫‪13,050.00‬‬ ‫‪13,050.00‬‬ ‫‪9,787.50‬‬

‫‪PM-8933570‬‬
‫طالب أحمد‬ ‫‪80601‬‬ ‫‪24567‬‬ ‫‪04/09/2021‬‬ ‫‪27,000.00‬‬ ‫‪27,000.00‬‬ ‫‪0.00‬‬

‫‪PM-8933669‬‬
‫عبير صقر‬ ‫‪81709‬‬ ‫‪24567‬‬ ‫‪07/09/2021‬‬ ‫‪15,800.00‬‬ ‫‪15,800.00‬‬ ‫‪11,850.00‬‬

‫‪PM-8934037‬‬
‫فداء محمد‬ ‫‪85925‬‬ ‫‪24567‬‬ ‫‪05/09/2021‬‬ ‫‪2,500.00‬‬ ‫‪2,500.00‬‬ ‫‪1,875.00‬‬

‫‪PM-8934158‬‬
‫لبنه مخلوف‬ ‫‪87217‬‬ ‫‪24567‬‬ ‫‪02/09/2021‬‬ ‫‪13,700.00‬‬ ‫‪13,700.00‬‬ ‫‪10,275.00‬‬

‫‪PM-8934256‬‬
‫مجد ابراهيم‬ ‫‪88522‬‬ ‫‪24567‬‬ ‫‪01/09/2021‬‬ ‫‪10,400.00‬‬ ‫‪10,400.00‬‬ ‫‪7,800.00‬‬

‫‪PM-8934387‬‬
‫مطيع علي‬ ‫‪90424‬‬ ‫‪24567‬‬ ‫‪02/09/2021‬‬ ‫‪15,300.00‬‬ ‫‪15,300.00‬‬ ‫‪11,475.00‬‬

‫‪PM-8934467‬‬
‫منى عيسى‬ ‫‪91424‬‬ ‫‪24567‬‬ ‫‪01/09/2021‬‬ ‫‪20,900.00‬‬ ‫‪20,900.00‬‬ ‫‪15,675.00‬‬

‫‪PM-8934471‬‬
‫منى سليمان‬ ‫‪91472‬‬ ‫‪24567‬‬ ‫‪02/09/2021‬‬ ‫‪16,100.00‬‬ ‫‪16,100.00‬‬ ‫‪12,075.00‬‬

‫‪PM-8934688‬‬
‫نده الدخيل‬ ‫‪94091‬‬ ‫‪24567‬‬ ‫‪01/09/2021‬‬ ‫‪12,000.00‬‬ ‫‪12,000.00‬‬ ‫‪9,000.00‬‬

‫‪PM-8934750‬‬
‫نظيرة علي‬ ‫‪94784‬‬ ‫‪24567‬‬ ‫‪01/09/2021‬‬ ‫‪10,200.00‬‬ ‫‪10,200.00‬‬ ‫‪7,650.00‬‬

‫‪PM-8934850‬‬
‫هال لوكان‬ ‫‪95725‬‬ ‫‪24567‬‬ ‫‪02/09/2021‬‬ ‫‪12,400.00‬‬ ‫‪12,400.00‬‬ ‫‪9,300.00‬‬

‫‪PM-8935007‬‬
‫وداد محمد‬ ‫‪97556‬‬ ‫‪24567‬‬ ‫‪04/09/2021‬‬ ‫‪9,200.00‬‬ ‫‪9,200.00‬‬ ‫‪6,900.00‬‬

‫‪PM-8935142‬‬
‫يوسف يوسف‬ ‫‪99043‬‬ ‫‪24567‬‬ ‫‪04/09/2021‬‬ ‫‪12,200.00‬‬ ‫‪12,200.00‬‬ ‫‪9,150.00‬‬

‫‪PM-8935629‬‬
‫فوزت الحجل‬ ‫‪139178‬‬ ‫‪24567‬‬ ‫‪06/09/2021‬‬ ‫‪17,400.00‬‬ ‫‪17,400.00‬‬ ‫‪13,050.00‬‬

‫‪PM-8936145‬‬
‫غادة سمرة‬ ‫‪176073‬‬ ‫‪24567‬‬ ‫‪02/09/2021‬‬ ‫‪10,000.00‬‬ ‫‪10,000.00‬‬ ‫‪7,500.00‬‬

‫‪PM-8936821‬‬
‫رحاب عبدالحميد‬ ‫‪220186‬‬ ‫‪24567‬‬ ‫‪05/09/2021‬‬ ‫‪6,000.00‬‬ ‫‪6,000.00‬‬ ‫‪4,500.00‬‬

‫‪PM-8936870‬‬
‫سندس مهنا‬ ‫‪224351‬‬ ‫‪24567‬‬ ‫‪02/09/2021‬‬ ‫‪15,100.00‬‬ ‫‪15,100.00‬‬ ‫‪11,325.00‬‬

‫‪PM-8937392‬‬
‫آسيا أبو طبيخ‬ ‫‪281304‬‬ ‫‪24567‬‬ ‫‪02/09/2021‬‬ ‫‪24,900.00‬‬ ‫‪24,900.00‬‬ ‫‪18,675.00‬‬

‫‪PM-8941705‬‬
‫نظيره طراف‬ ‫‪94783‬‬ ‫‪24567‬‬ ‫‪02/09/2021‬‬ ‫‪22,700.00‬‬ ‫‪22,700.00‬‬ ‫‪10,762.50‬‬

‫‪PM-8946138‬‬
‫هودا محمد‬ ‫‪96804‬‬ ‫‪24567‬‬ ‫‪07/09/2021‬‬ ‫‪8,765.00‬‬ ‫‪8,765.00‬‬ ‫‪6,573.75‬‬

‫‪PM-8946794‬‬
‫أحمد محمد‬ ‫‪124470‬‬ ‫‪24773‬‬ ‫‪08/09/2021‬‬ ‫‪12,700.00‬‬ ‫‪12,700.00‬‬ ‫‪9,525.00‬‬

‫‪PM-8947071‬‬
‫أحمد خير بك‬ ‫‪124454‬‬ ‫‪24773‬‬ ‫‪08/09/2021‬‬ ‫‪12,700.00‬‬ ‫‪12,700.00‬‬ ‫‪9,525.00‬‬

‫‪PM-8947622‬‬
‫هديل جمعه‬ ‫‪324576‬‬ ‫‪24567‬‬ ‫‪09/09/2021‬‬ ‫‪13,900.00‬‬ ‫‪13,900.00‬‬ ‫‪10,425.00‬‬

‫‪PM-8947883‬‬
‫بشار عيسى‬ ‫‪179723‬‬ ‫‪24886‬‬ ‫‪09/09/2021‬‬ ‫‪17,100.00‬‬ ‫‪17,100.00‬‬ ‫‪12,825.00‬‬
 Provider Claims Statements Page 2 of 7

Pack# 9094(Network) Date: 11/11/2021 5:59:38PM

Sep claims 2021 SIC (Pharmacies)
Provider: P1708-Isra Dauod Pharmacy Curr: SP-Syrian Pound
Payer: 45 Syrian Insurance Company

Reference Patient Policy# Date Claimed Amnt Total Approved Payer Share

PM-8949182
‫مرام الهوشي‬ 217776 24567 12/09/2021 16,500.00 11,900.00 8,925.00
Item Code Description Qty: Claimed Approved Claimed Amnt Approved Amnt Adjustment Reason

PM.2097 LANSOPRAL 30 MG 20 CAP 1 0 2,100.00 0.00 ‫الموجودات الحالية ل تستدعي الموافقة على‬
‫الخدمة ا‬

PM.8679 TULLIN EXTRA 20 SOFT GELATIN CAP 1 1 3,500.00 3,500.00

PM.3966 ASIA-PROFEN 600 mg 20 soft gel.cap. 1 1 3,200.00 3,200.00

PM.5791 ZEDNAD 500 MG 10 TAB 1 1 5,200.00 5,200.00

PM.8366 BROMONASE FORT 30 TAB 1 0 2,500.00 0.00 ‫الموجودات الحالية ل تستدعي الموافقة على‬
‫الخدمة ا‬

PM-8951014
‫روزيت عثمان‬ 139960 24567 14/09/2021 9,100.00 6,500.00 4,875.00
Item Code Description Qty: Claimed Approved Claimed Amnt Approved Amnt Adjustment Reason

PM.8509 DAFLOGOLD 30 TAB 1 1 3,800.00 3,800.00

PM.7279 DELASTOM 30 MG 24 CAP 1 0 2,600.00 0.00 ‫الدواء مرفوض كونه غير متوافق مع اختصاص‬
‫الطبيب‬

PM.6068 FLAM-K 50 MG 20 TAB 1 1 1,400.00 1,400.00

PM.7130 CURANUS 30 G OINT 1 1 1,300.00 1,300.00

PM-8951025
‫وهيبة صبيح‬ 222349 23502 14/09/2021 13,400.00 10,800.00 7,625.00
Item Code Description Qty: Claimed Approved Claimed Amnt Approved Amnt Adjustment Reason

PM.8662 ZOMOLAND 20 CAP 1 1 1,900.00 1,900.00

PM.7273 NEBROGET 20 TAB 1 1 1,800.00 1,800.00

PM.5980 ARTROFEN 50 G GEL 1 1 4,400.00 4,400.00

PM.6974 NOXIDARA 40 MG 30 TAB 1 0 2,600.00 0.00 ‫الموجودات الحالية ل تستدعي الموافقة على‬
‫الخدمة ا‬

PM.7425 TORICOX 90 MG 20 TAB 1 1 2,700.00 2,700.00

PM-8951067
‫فاتن اسعد‬ 84806 24567 14/09/2021 10,000.00 7,500.00 5,625.00
Item Code Description Qty: Claimed Approved Claimed Amnt Approved Amnt Adjustment Reason

PM.8662 ZOMOLAND 20 CAP 1 1 1,900.00 1,900.00

PM.1093 OMEPRAL 40 MG 14 CAP 1 0 2,500.00 0.00 ‫الموجودات الحالية ل تستدعي الموافقة على‬
‫الخدمة ا‬

PM.949 VITA 3 10 AMP (5A+5B) 1 1 3,800.00 3,800.00

PM.8594 DICLOTAMOL-K 20 TAB 1 1 1,800.00 1,800.00

 Provider Claims Statements Page 3 of 7

Pack# 9094(Network) Date: 11/11/2021 5:59:38PM

Sep claims 2021 SIC (Pharmacies)
Provider: P1708-Isra Dauod Pharmacy Curr: SP-Syrian Pound
Payer: 45 Syrian Insurance Company

Reference Patient Policy# Date Claimed Amnt Total Approved Payer Share

PM-8951733
‫هاني سلطان‬ 177820 24567 14/09/2021 22,300.00 19,800.00 14,850.00
Item Code Description Qty: Claimed Approved Claimed Amnt Approved Amnt Adjustment Reason

PM.7124 AGILOMOX 20 TAB 1 1 1,600.00 1,600.00

PM.7497 ROCIFLEX - PLUSS 1500 1 VIAL 6 6 12,600.00 12,600.00

PM.8366 BROMONASE FORT 30 TAB 1 0 2,500.00 0.00 ‫الموجودات الحالية ل تستدعي الموافقة على‬
‫الخدمة ا‬

PM.5857 ESOSTOME 40 MG 20 CAP 1 1 1,900.00 1,900.00

PM.1715 RHINO-FORT 20 tab 1 1 1,500.00 1,500.00

PM.6549 NASACLEAR 15 ML NASAL SPRAY 1 1 2,200.00 2,200.00

PM-8954207
‫إباء الهوشي‬ 139918 24567 18/09/2021 10,000.00 10,000.00 7,500.00

PM-8955433
‫نازك غناجو‬ 220657 24567 19/09/2021 7,000.00 7,000.00 5,250.00

PM-8955436
‫ياسين ابراهيم‬ 98714 24567 19/09/2021 12,200.00 8,200.00 6,150.00
Item Code Description Qty: Claimed Approved Claimed Amnt Approved Amnt Adjustment Reason

PM.4802 KLACID 500 MG 14 TAB 1 1 4,200.00 4,200.00

PM.5957 CETACODEINE 30 TAB 1 1 2,600.00 2,600.00

PM.6095 PHARMACORT 20 MG 30 TAB 1 0 2,200.00 0.00 ‫الموجودات الحالية ل تستدعي الموافقة على‬
‫الخدمة ا‬

PM.1726 BRONCOPHYLLINE 20 TAB 1 1 1,400.00 1,400.00

PM.7544 NEXI LONG 40 MG 20 CAP 1 0 1,800.00 0.00 ‫الموجودات الحالية ل تستدعي الموافقة على‬
‫الخدمة ا‬

PM-8955442
‫بقاء حسن‬ 68920 24567 19/09/2021 11,000.00 11,000.00 8,250.00

PM-8956466
‫وائل حماد‬ 220356 24567 20/09/2021 10,900.00 8,400.00 6,300.00
Item Code Description Qty: Claimed Approved Claimed Amnt Approved Amnt Adjustment Reason

PM.7265 DEXABIOTIC 5 ML OTIC DROPS 1 1 900.00 900.00

PM.6068 FLAM-K 50 MG 20 TAB 1 1 1,400.00 1,400.00

PM.8366 BROMONASE FORT 30 TAB 1 0 2,500.00 0.00 ‫الموجودات الحالية ل تستدعي الموافقة على‬
‫الخدمة ا‬

PM.1161 TRIDERM 15 G CREAM 1 1 900.00 900.00

PM.5791 ZEDNAD 500 MG 10 TAB 1 1 5,200.00 5,200.00

PM-8957563
‫لينا عثمان‬ 87866 24567 21/09/2021 12,900.00 9,900.00 7,425.00
Item Code Description Qty: Claimed Approved Claimed Amnt Approved Amnt Adjustment Reason

PM.8366 BROMONASE FORT 30 TAB 1 1 2,500.00 2,500.00

PM.201 DICLOFENAC 100 MG 10 SUPP 1 0 1,200.00 0.00 ‫الموجودات الحالية ل تستدعي الموافقة على‬
‫الخدمة ا‬

PM.4164 CEFIXIM-ELSAAD 400 MG 10 TAB 1 1 5,500.00 5,500.00

PM.2359 FUCIDATE 20g.cream 1 1 1,900.00 1,900.00

PM.1352 FLAGYL 500 MG 20 TAB 1 0 1,800.00 0.00 ‫الموجودات الحالية ل تستدعي الموافقة على‬
‫الخدمة ا‬
 Provider Claims Statements Page 4 of 7

Pack# 9094(Network) Date: 11/11/2021 5:59:38PM

Sep claims 2021 SIC (Pharmacies)
Provider: P1708-Isra Dauod Pharmacy Curr: SP-Syrian Pound
Payer: 45 Syrian Insurance Company

Reference Patient Policy# Date Claimed Amnt Total Approved Payer Share

PM-8958181
‫فر محرز‬ 86243 24567 21/09/2021 15,400.00 15,400.00 11,550.00

PM-8958192
‫هدى عثمان‬ 96235 24567 21/09/2021 11,400.00 9,200.00 6,900.00
Item Code Description Qty: Claimed Approved Claimed Amnt Approved Amnt Adjustment Reason

PM.8744 HUMAFER 20 TAB 1 0 2,200.00 0.00 ‫الخدمة يجب أن تحال من طبيب مختص‬

PM.2344 FUCINE 20g.cream 1 1 1,900.00 1,900.00

PM.8594 DICLOTAMOL-K 20 TAB 1 1 1,800.00 1,800.00

PM.4164 CEFIXIM-ELSAAD 400 MG 10 TAB 1 1 5,500.00 5,500.00

PM-8959061
‫نضال علوش‬ 94743 24567 22/09/2021 7,365.00 7,365.00 5,523.75

PM-8961460
‫آمال الدخيل‬ 66579 24567 26/09/2021 19,100.00 19,100.00 14,325.00

PM-8961516
‫سوزانا جديد‬ 150223 23171 26/09/2021 22,000.00 14,200.00 10,650.00
Item Code Description Qty: Claimed Approved Claimed Amnt Approved Amnt Adjustment Reason

PM.8681 SEASPAN 100 ML SYRUP 1 1 4,000.00 4,000.00

PM.8366 BROMONASE FORT 30 TAB 1 0 2,500.00 0.00 ‫الموجودات الحالية ل تستدعي الموافقة على‬
‫الخدمة ا‬

PM.3966 ASIA-PROFEN 600 mg 20 soft gel.cap. 1 0 3,200.00 0.00 ‫الموجودات الحالية ل تستدعي الموافقة على‬
‫الخدمة ا‬

PM.5791 ZEDNAD 500 MG 10 TAB 1 1 5,200.00 5,200.00

PM.1496 MUCOLAR 375 MG 20 CAP 1 1 1,500.00 1,500.00

PM.8679 TULLIN EXTRA 20 SOFT GELATIN CAP 1 1 3,500.00 3,500.00

PM.7072 LANSOPRAZOLE 30 MG 20 CAP 1 0 2,100.00 0.00 ‫الموجودات الحالية ل تستدعي الموافقة على‬
‫الخدمة ا‬

PM-8961893
‫جهيده احمد‬ 187523 24570 26/09/2021 10,300.00 10,300.00 7,725.00

PM-8962501
‫ديما حسن‬ 72653 24567 27/09/2021 9,450.00 6,250.00 4,687.50
Item Code Description Qty: Claimed Approved Claimed Amnt Approved Amnt Adjustment Reason

PM.2344 FUCINE 20g.cream 1 1 1,900.00 1,900.00

PM.6068 FLAM-K 50 MG 20 TAB 1 0 1,400.00 0.00 ‫الموجودات الحالية ل تستدعي الموافقة على‬
‫الخدمة ا‬

PM.8366 BROMONASE FORT 30 TAB 1 1 2,500.00 2,500.00

PM.1352 FLAGYL 500 MG 20 TAB 1 0 1,800.00 0.00 ‫الموجودات الحالية ل تستدعي الموافقة على‬
‫الخدمة ا‬

PM.8550 HAYACILLINE 1000 MG 20 TAB 1 1 1,850.00 1,850.00

 Provider Claims Statements Page 5 of 7

Pack# 9094(Network) Date: 11/11/2021 5:59:38PM

Sep claims 2021 SIC (Pharmacies)
Provider: P1708-Isra Dauod Pharmacy Curr: SP-Syrian Pound
Payer: 45 Syrian Insurance Company

Reference Patient Policy# Date Claimed Amnt Total Approved Payer Share

PM-8962699
‫ندى محمد‬ 94167 24567 27/09/2021 14,000.00 10,700.00 8,025.00
Item Code Description Qty: Claimed Approved Claimed Amnt Approved Amnt Adjustment Reason

PM.8978 UNEX 30 TAB 1 1 2,500.00 2,500.00

PM.2841 DE-SPASM 30ctd tab 1 1 2,700.00 2,700.00

PM.5857 ESOSTOME 40 MG 20 CAP 1 0 1,900.00 0.00 ‫الموجودات الحالية ل تستدعي الموافقة على‬
‫الخدمة ا‬

PM.4164 CEFIXIM-ELSAAD 400 MG 10 TAB 1 1 5,500.00 5,500.00

PM.2426 BRUFEN 400 MG 24 TAB 1 0 1,400.00 0.00 ‫الموجودات الحالية ل تستدعي الموافقة على‬
‫الخدمة ا‬

PM-8962721
‫فاتن حسن‬ 281340 24567 27/09/2021 10,300.00 6,500.00 4,875.00
Item Code Description Qty: Claimed Approved Claimed Amnt Approved Amnt Adjustment Reason

PM.8509 DAFLOGOLD 30 TAB 1 1 3,800.00 3,800.00

PM.5957 CETACODEINE 30 TAB 1 0 2,600.00 0.00 ‫الموجودات الحالية ل تستدعي الموافقة على‬
‫الخدمة ا‬

PM.2346 LIDODERM 20g.cream 1 1 1,400.00 1,400.00

PM.987 DICLON 100 MG 10 SUPP 1 0 1,200.00 0.00 ‫الموجودات الحالية ل تستدعي الموافقة على‬
‫الخدمة ا‬

PM.7130 CURANUS 30 G OINT 1 1 1,300.00 1,300.00

PM-8965776
‫منال سلهب‬ 305224 24567 29/09/2021 13,300.00 13,300.00 9,975.00

PM-8966162
‫أمل أحمد‬ 66964 24567 30/09/2021 14,900.00 14,900.00 11,175.00

53 claim(s) Total 730,630.00 686,030.00 487,535.00

 Provider Claims Statements Page 6 of 7

Pack# 9094(Network) Date: 11/11/2021 5:59:38PM

Sep claims 2021 SIC (Pharmacies)
Provider: P1708-Isra Dauod Pharmacy Curr: SP-Syrian Pound
Payer: 45P Syrian Insurance Company Private

Reference Patient Policy# Date Claimed Amnt Total Approved Payer Share

PM-8961700
‫وفيق سلوم‬ 296610 23530 26/09/2021 9,200.00 9,200.00 8,280.00

1 claim(s) Total 9,200.00 9,200.00 8,280.00

 Provider Claims Statements Page 7 of 7

Pack# 9094(Network) Date: 11/11/2021 5:59:38PM

Sep claims 2021 SIC (Pharmacies)

Provider Payer Payment Claimed Approved Payer

Code Due date Curr Amount Amount Share

P1708-Isra Dauod Pharmacy 45 29/11/2021 SP 53 730,630.00 686,030.00 487,535.00

Pay To: BEMO Jableh 0369062 Isra Asaad Dauod

P1708-Isra Dauod Pharmacy 45P 29/11/2021 SP 1 9,200.00 9,200.00 8,280.00

Pay To: BEMO Jableh 0369062 Isra Asaad Dauod

Grand Total by Currency SP 54 739,830.00 695,230.00 495,815.00