28/09/2022

Explanation of Benefits
Risk Carrier : Wethaq Policy Holder Name : Wadi Degla Clubs
Member : 50019193 50506235 Staff # : 3222 Provider : Saudi German Hospital Pharmacy
Claim Number :
MCN : 50620298 Batch # : 0
Principal Name : ‫ﻉ ﻓﻮﺯﻱ ﺭﺍﻣﺰ‬
Name : ‫ﺭﺍﻣﺰ ﻓﻮﺯﻱ‬
Date Of Birth : 1991

Transaction Date : 28/09/2022 Invoice Number : 41277305 Physician : Saudi German Hospital Cairo Default Doctor
Diagnosis : Disorder of prostate, unspecified Approved by

Detailed Bill Med File : Cons. Fees : 0.00 EGP SSNBR : 59344663

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

PHARMACY 1- CELEBREX Caps 200 mg 15 caps / 1 113.500 Box 1 EGP 113.500 1 113.500 11.350
CAPS 2 time(s) per day(s) for7 day(s)
2- DAFLON Tabs 500 mg 30 tabs / 1 64.500 Box 2 EGP 129.000 2 129.000 12.900
TABS 2 time(s) per day(s) for28 day(s)
3- PROST-ADE Caps 20 caps / 1 CAPS 2 63.000 Box 3 EGP 189.000 3 189.000 18.900
time(s) per day(s) for28 day(s)

Summary Patient Share

Total Claimed 431.500 EGP Co-Insurance 77.670 EGP
Total Approved 431.500 EGP Exceeding Limitation 0.000 EGP
Discount 43.150 EGP Uncovered Items 0.000 EGP

Net Amount 310.680 EGP Total Patient Share 77.670 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