Medical expenses - 40s woman with UC
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Date of ServiceProvider/ FacilityStatusDrug NameClaim Amount/ Prescription CostPaid by PlanYou May Pay
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11/1/2012GI specialistCompleted18937.830
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11/1/2012Hospital facility chargeNot Approved16000
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11/1/2012OphtalmologistCompleted160149.870
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10/15/2012Ob-gynCompleted230150.230
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10/15/2012Pap smear pathologyCompleted9527.240
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10/1/2012Colonoscopy - hospital chargesCompleted101711922.59500
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10/1/2012Colonoscopy - pathologyCompleted1020269.930
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10/1/2012Colonoscopy - AnesthesiologistCompleted1600785.70
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10/1/2012Colonoscopy - GI specialistCompleted1026245.590
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9/21/2012Primary care NPCompleted11523.150
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9/21/2012Strep testCompleted69.978.910
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9/11/2012GI specialistCompleted18937.830
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9/11/2012Hospital facility chargeNot Approved16000
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8/20/2012Primary care MD follow-upCompleted853.5150
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8/13/2012Blood testsCompleted159.0722.570
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8/6/2012Blood testsCompleted384.7349.110
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8/6/2012Hospital facility chargeNot Approved16000
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8/6/2012GI specialistCompleted9819.60
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5/17/2012PCP yearly physicalCompleted430204.930
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5/11/2012Blood testsCompleted781.75100.610
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2/3/2012PCP new patientCompleted17048.4150
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1/12/2012GI specialistCompleted9819.60
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1/12/2012Hospital facility chargeNot Approved23000
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12/21/2012PharmacyCompletedASACOL TAB 400MG DR363.27328.2735
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11/17/2012PharmacyCompletedMESALAMINE 383.36368.3615
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10/27/2012PharmacyCompletedASACOL TAB 400MG DR363.27328.2735
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9/21/2012PharmacyCompletedAMOXICILLIN CAP 500MG404
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9/21/2012PharmacyCompletedASACOL TAB 400MG DR363.27328.2735
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9/21/2012PharmacyCompletedMESALAMINE 383.36368.3615
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8/6/2012PharmacyCompletedMESALAMINE 383.36368.3615
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8/6/2012PharmacyCompletedASACOL TAB 400MG DR363.27328.2735
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Totals 201220388.686545.32839
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2011
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9/19/2011Ob-gynCompleted230150.230
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9/19/2011Pap smear pathologyCompleted27.6727.670
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7/21/2011PCP new patientCompleted28000
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7/21/2011Hospital facility chargeNot Approved8800
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7/5/2011GI specialistCompleted12637.830
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7/5/2011Hospital facility chargeNot Approved6800
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3/17/2011Blood testsCompleted2532176.590
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3/17/2011GI specialistCompleted41560.060
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1/29/2011Flu shotCompleted22.522.50
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3/17/2011PharmacyCompletedMESALAMINE 236.7221.715
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Totals 20114025.87696.5815
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