Provider Claims Statements Page 1 of 4

Pack# 9158(Network) Date: 11/11/2021 5:59:21PM

Oct 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-8968582
‫محمد عيسى‬ 147385 23992 02/10/2021 9,800.00 9,800.00 7,350.00

PM-8969158
‫أمل أحمد‬ 66964 24567 02/10/2021 14,300.00 14,300.00 10,725.00

PM-8969600
‫خولة عيسى‬ 72130 24567 10/10/2021 16,400.00 16,400.00 12,300.00

PM-8969760
‫رغداء أحمد‬ 74117 24567 02/10/2021 14,800.00 14,800.00 11,100.00

PM-8969793
‫رندلين عيسى‬ 74665 24567 03/10/2021 23,700.00 23,700.00 17,775.00

PM-8970179
‫سوسن احمد‬ 79383 24567 03/10/2021 9,600.00 9,600.00 7,200.00

PM-8970282
‫طالب أحمد‬ 80601 24567 02/10/2021 28,400.00 28,400.00 0.00

PM-8970383
‫عبير صقر‬ 81709 24567 03/10/2021 12,400.00 12,400.00 9,300.00

PM-8970739
‫فداء محمد‬ 85925 24567 06/10/2021 2,500.00 2,500.00 1,875.00

PM-8970859
‫لبنه مخلوف‬ 87217 24567 03/10/2021 7,600.00 7,600.00 5,700.00

PM-8970947
‫مجد ابراهيم‬ 88522 24567 02/10/2021 15,300.00 15,300.00 11,475.00

PM-8971077
‫مطيع علي‬ 90424 24567 02/10/2021 14,700.00 14,700.00 2,437.50

PM-8971164
‫منى عيسى‬ 91424 24567 01/10/2021 23,500.00 23,500.00 14,025.00

PM-8971167
‫منى سليمان‬ 91472 24567 02/10/2021 16,400.00 16,400.00 12,300.00

PM-8971435
‫نظيره طراف‬ 94783 24567 04/10/2021 24,400.00 24,400.00 0.00

PM-8971535
‫هال لوكان‬ 95725 24567 02/10/2021 18,300.00 18,300.00 13,725.00

PM-8971677
‫وداد محمد‬ 97556 24567 02/10/2021 9,200.00 9,200.00 6,900.00

PM-8971805
‫يوسف يوسف‬ 99043 24567 02/10/2021 14,200.00 14,200.00 10,650.00

PM-8972300
‫فوزت الحجل‬ 139178 24567 06/10/2021 13,200.00 13,200.00 9,900.00

PM-8972817
‫غادة سمرة‬ 176073 24567 02/10/2021 6,600.00 6,600.00 4,950.00

PM-8973493
‫رحاب عبدالحميد‬ 220186 24567 03/10/2021 10,100.00 10,100.00 7,575.00

PM-8973546
‫سندس مهنا‬ 224351 24567 04/10/2021 20,000.00 20,000.00 15,000.00

PM-8974065
‫آسيا أبو طبيخ‬ 281304 24567 02/10/2021 20,000.00 20,000.00 5,025.00

PM-8975964
‫جهيده احمد‬ 187523 24570 02/10/2021 9,400.00 9,400.00 7,050.00

PM-8977155
‫مجد ابراهيم‬ 88522 24567 02/10/2021 7,200.00 7,200.00 5,400.00

PM-8978590
‫أحمد الشاعر‬ 65021 24567 04/10/2021 21,000.00 12,200.00 9,150.00
Item Code Description Qty: Claimed Approved Claimed Amnt Approved Amnt Adjustment Reason

PM.6549 NASACLEAR 15 ML NASAL SPRAY 5 1 11,000.00 2,200.00

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

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

PM.8510 NOFLU-HBP 20 CAPLETES 1 1 1,700.00 1,700.00

PM.599 AZMEX 100 ML SYR 1 1 1,400.00 1,400.00

PM-8979134
‫شهناز دياب‬ 79926 24567 05/10/2021 13,500.00 13,500.00 10,125.00
 Provider Claims Statements Page 2 of 4

Pack# 9158(Network) Date: 11/11/2021 5:59:21PM

Oct 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-8979667
‫لينده سعود‬ 88074 24567 05/10/2021 12,600.00 10,700.00 8,025.00
Item Code Description Qty: Claimed Approved Claimed Amnt Approved Amnt Adjustment Reason

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

PM.8341 HUMAFORTE 10 MG 20 TAB 1 0 1,900.00 0.00 ‫الخدمة مرفوضة لعد توافقها مع اختصاص الطبيب‬

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

PM.5863 AUGMENTIN 1 G 14 TAB 1 1 7,000.00 7,000.00

PM-8983197
‫فادي علي‬ 166500 24567 10/10/2021 8,900.00 8,900.00 6,675.00

PM-8983911
‫ملكة يوسف‬ 90786 24567 10/10/2021 17,100.00 17,100.00 12,825.00

PM-8985667
‫نجيبه جرعا‬ 94043 24567 12/10/2021 13,000.00 10,400.00 7,800.00
Item Code Description Qty: Claimed Approved Claimed Amnt Approved Amnt Adjustment Reason

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

PM.6908 INDITRO 75 MG 28 TAB 1 0 2,600.00 0.00 ‫الموجودات الحالية ل تستدعي الموافقة على‬
‫الخدمة ا‬

PM.8905 ARCO 90 MG 20 TAB 1 1 2,700.00 2,700.00

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

PM.4135 CARISOL 350 MG 20 TAB 1 1 1,400.00 1,400.00

PM-8987070
‫ايمان عمار‬ 134589 24567 13/10/2021 7,365.00 7,365.00 5,523.75

PM-8992820
‫أماني داود‬ 124507 24773 20/10/2021 12,000.00 12,000.00 9,000.00

PM-8995176
‫هنادي يوسف‬ 226902 24567 23/10/2021 17,600.00 15,800.00 11,850.00
Item Code Description Qty: Claimed Approved Claimed Amnt Approved Amnt Adjustment Reason

PM.5137 OMNI 300 MG 10 TAB 1 1 4,200.00 4,200.00

PM.7497 ROCIFLEX - PLUSS 1500 1 VIAL 4 4 8,400.00 8,400.00

PM.2231 DANIZINE FORTE 20 ctd.tab 1 0 1,800.00 0.00 ‫الموجودات الحالية ل تستدعي الموافقة على‬
‫الخدمة ا‬

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

PM-8995179
‫آلء حسن‬ 306047 24567 23/10/2021 12,600.00 8,800.00 6,600.00
Item Code Description Qty: Claimed Approved Claimed Amnt Approved Amnt Adjustment Reason

PM.5137 OMNI 300 MG 10 TAB 1 1 4,200.00 4,200.00

PM.6078 CLINDO-PLUS 300 MG 12 CAP 1 0 3,800.00 0.00 ‫الموجودات الحالية ل تستدعي الموافقة على‬
‫الخدمة ا‬

PM.8341 HUMAFORTE 10 MG 20 TAB 1 1 1,900.00 1,900.00

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

 Provider Claims Statements Page 3 of 4

Pack# 9158(Network) Date: 11/11/2021 5:59:21PM

Oct 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-8996443
‫فتاة شهرة‬ 91526 24567 25/10/2021 12,900.00 10,700.00 8,025.00
Item Code Description Qty: Claimed Approved Claimed Amnt Approved Amnt Adjustment Reason

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

PM.1352 FLAGYL 500 MG 20 TAB 1 1 1,800.00 1,800.00

PM.5940 DUSPALINA ASIA 200 MG 30 CAP 1 1 3,400.00 3,400.00

PM.8642 LANSOLANT 30 MG 20 CAP 1 0 2,200.00 0.00 ᔁ ‫نفس الدواء من نفس التركيب تم أخذه سابقا‬

PM-8998075
‫فداء محمد‬ 85925 24567 26/10/2021 10,100.00 10,100.00 7,575.00

PM-8998080
‫حيدر يوسف‬ 177241 24567 26/10/2021 10,100.00 10,100.00 7,575.00

PM-9001377
‫جهيده احمد‬ 187523 24570 30/10/2021 5,500.00 4,600.00 3,450.00
Item Code Description Qty: Claimed Approved Claimed Amnt Approved Amnt Adjustment Reason

PM.7020 AZOCIN 500 MG 3 CAP 1 1 1,600.00 1,600.00

PM.2028 GRIPPE STOP 20 TAB 1 1 1,500.00 1,500.00

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

PM.5965 SYTAMOL 500 MG 10 TAB 1 0 900.00 0.00 ‫الحالة مستثناة من شروط التغطية‬

PM-9001612
‫سوسن روميه‬ 79368 24567 31/10/2021 14,700.00 7,500.00 1,951.25
Item Code Description Qty: Claimed Approved Claimed Amnt Approved Amnt Adjustment Reason

PM.2979 MOTIN 10 MG 40 TAB 1 1 2,300.00 2,300.00

PM.4164 CEFIXIM-ELSAAD 400 MG 10 TAB 1 0 5,500.00 0.00 ‫الموجودات الحالية ل تستدعي الموافقة على‬
‫الخدمة ا‬

PM.5940 DUSPALINA ASIA 200 MG 30 CAP 1 1 3,400.00 3,400.00

PM.6210 RABEMAX 20 MG 20 TAB 1 0 1,700.00 0.00 ‫الموجودات الحالية ل تستدعي الموافقة على‬
‫الخدمة ا‬

PM.1352 FLAGYL 500 MG 20 TAB 1 1 1,800.00 1,800.00

PM-9001755
‫رويدة مرهج‬ 75077 24567 31/10/2021 13,600.00 13,600.00 10,200.00

41 claim(s) Total 564,565.00 535,365.00 336,087.50

 Provider Claims Statements Page 4 of 4

Pack# 9158(Network) Date: 11/11/2021 5:59:21PM

Oct claims 2021 SIC (Pharmacies)

Provider Payer Payment Claimed Approved Payer

Code Due date Curr Amount Amount Share

P1708-Isra Dauod Pharmacy 45 30/12/2021 SP 41 564,565.00 535,365.00 336,087.50

Pay To: BEMO Jableh 0369062 Isra Asaad Dauod

Grand Total by Currency SP 41 564,565.00 535,365.00 336,087.50