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Prescription DrugEOB-2024-001156
Denver Pharmacy
Service Date: September 22, 2024
$127.89
Total Charged
Financial Breakdown
$127.89
Total Charged
$98.45
Medicare Paid
$29.44
You Paid
$29.44
Coinsurance Applied
Service Details
Services Provided
| Service | Code | Qty | Charged | Allowed | Paid |
|---|---|---|---|---|---|
| Lisinopril 10mg (30-day supply) | 68180-0519-06 | 30 | $127.89 | $115.10 | $98.45 |
Diagnosis Information
Primary Diagnosis
I10
Essential hypertension
Provider Information
- Provider:
- Denver Pharmacy
- Provider Type:
- Pharmacy
- NPI:
- 5555666677
- Place of Service:
- Pharmacy (01)
Claim Information
- Claim ID:
- EOB-2024-001156
- Service Date:
- September 22, 2024
- End Date:
- September 22, 2024
- Processed Date:
- September 25, 2024
- Status:
- APPROVED
Coverage Analysis
Medicare Coverage
Covered Service
Part DThis service is covered under your Medicare plan. No deductible was applied.
Cost Breakdown
Provider Charged:$127.89
Medicare Allowed:$108.71
Medicare Paid:$98.45
Coinsurance (20%):$29.44
Your Responsibility:$29.44
AI Analysis
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