Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| PRIVATE | PR | Secondary | |||
| YESSICA'S TEST OPEN ITEM | Secondary |
PSB F6 E1 · Manual exception
Routine B1 processing uses active coverage already on file and does not call E1. Use this manual check only when eligibility is uncertain. Results are coverage proposals; applying coverage remains a separate user decision.
| Result | Mode | Actor | Response | Recorded |
|---|---|---|---|---|
| No E1 eligibility evidence recorded. | ||||
| Medication | Sig | Qty / days supply | Refills remaining | Last fill | Next due | Status |
|---|---|---|---|---|---|---|
| GAVISCON 80-20MG TAB 00088117547 · Rx 36943 |
— | 120 / 30 days | 98 of 99 | 2026-06-30 | 2026-07-30 | Overdue |
| MOTRIN 400MG TAB 400MG 00009738502 · Rx 36942 |
— | 56 / 28 days | 98 of 99 | 2026-06-30 | 2026-07-28 | Overdue |
| TYLENOL 325MG TAB 325MG 50580050130 · Rx 36898 |
— | 28 / 28 days | 97 of 99 | 2026-06-30 | 2026-07-28 | Overdue |
| FUROSEMIDE 20MG TAB 20MG 63304062401 · Rx 36954 |
— | 7 / 7 days | 6 of 7 | 2026-06-30 | 2026-07-07 | Overdue |
| HYDROXYZINE PAM 25MG CAP 25MG 00185067401 · Rx 36739 |
— | 14 / 7 days | 98 of 99 | 2026-05-19 | 2026-05-26 | Overdue |
| QUETIAPINE 25MG TAB 25MG 67877024210 · Rx 36589 |
— | 7 / 7 days | 8 of 10 | 2026-05-19 | 2026-05-26 | Overdue |
| SAM-QUETIAPINE 200MG TAB 100MG 67877025001 · Rx 36588 |
— | 7 / 7 days | 3 of 5 | 2026-05-19 | 2026-05-26 | Overdue |
| INVEGA 9MG TAB 9MG 50458055201 · Rx 36594 |
— | 30 / 30 days | 5 of 5 | 2026-03-23 | 2026-04-22 | Overdue |
| HYDROXYZ PAM 25MG CAP 25MG 00591080005 · Rx 36590 |
— | 28 / 7 days | 9 of 10 | 2026-03-30 | 2026-04-06 | Overdue |
| PAP-INVEGA SUST 117/0.75 INJ 117/0.75 50458056201 · Rx 36619 |
— | 0.75 / 1 days | 0 of 0 | 2026-03-30 | 2026-03-31 | Completed |
| HYDROCHLOROT 25MG TAB 25MG 00603385632 · Rx 760 |
— | 28 / 28 days | 0 of 1 | 2008-08-13 | 2008-09-10 | Completed |
| VITAMIN E 400IU CAP 400UNIT 00904027460 · Rx 759 |
— | 84 / 28 days | 0 of 1 | 2008-08-13 | 2008-09-10 | Completed |
| VITAMIN C 500MG TAB 500MG 00603032521 · Rx 758 |
— | 28 / 28 days | 0 of 1 | 2008-08-13 | 2008-09-10 | Completed |
| SEROQUEL 25MG TAB 25MG 00310027510 · Rx 757 |
— | 140 / 28 days | 0 of 1 | 2008-08-13 | 2008-09-10 | Completed |
| WARFARIN 4MG TAB 4MG 00555087402 · Rx 756 |
— | 2 / 28 days | 0 of 1 | 2008-08-13 | 2008-09-10 | Completed |
| WARFARIN 1MG TAB 1MG 51672402701 · Rx 755 |
— | 5 / 28 days | 0 of 1 | 2008-08-13 | 2008-09-10 | Completed |
| ASPIR-LOW 81MG EC TAB 81MG EC 00904770418 · Rx 754 |
— | 28 / 28 days | 0 of 1 | 2008-08-13 | 2008-09-10 | Completed |
| GLIPIZIDE 10MG TAB 10MG 60505014200 · Rx 753 |
— | 28 / 28 days | 0 of 1 | 2008-08-13 | 2008-09-10 | Completed |
| ARICEPT 10MG TAB 10MG 62856024630 · Rx 752 |
— | 28 / 28 days | 0 of 1 | 2008-08-13 | 2008-09-10 | Completed |
| HYDROXYZ PAM 25MG CAP 25MG 00185061301 · Rx 767 |
— | 60 / 30 days | 0 of 0 | 2008-07-01 | 2008-07-31 | Completed |
| ACETAMIN 325MG TAB 325MG 10135012301 · Rx 768 |
— | 56 / 28 days | 0 of 0 | 2008-07-01 | 2008-07-29 | Completed |
| AMOXICILLIN 250MG CAP 250MG 00093310701 · Rx 761 |
— | 84 / 28 days | 0 of 0 | 2008-06-30 | 2008-07-28 | Completed |
| STRATTERA 10MG CAP 10MG 00002322730 · Rx 378 |
— | 56 / 28 days | 0 of 4 | 2007-06-22 | 2007-07-20 | Completed |
| ACETAMIN 500MG TAB 500MG 10135015210 · Rx 379 |
— | 336 / 28 days | 2 of 5 | 2007-05-22 | 2007-06-19 | Overdue |
| ZOLOFT 20MG/ML CON 20MG/ML 00049494023 · Rx 492 |
— | 60 / 24 days | 0 of 0 | 2007-04-10 | 2007-05-04 | Completed |
| ACETAMIN 500MG TAB 500MG 10135015210 · Rx 65 |
— | 360 / 30 days | 0 of 5 | 2006-12-22 | 2007-01-21 | Completed |
| STRATTERA 10MG CAP 10MG 00002322730 · Rx 64 |
— | 60 / 30 days | 0 of 4 | 2006-12-22 | 2007-01-21 | Completed |
| SONATA 10MG CAP 10MG 60793014601 · Rx 63 |
— | 30 / 30 days | 0 of 4 | 2006-12-15 | 2007-01-14 | Completed |
| CYMBALTA 30MG CAP 30MG 00002324030 · Rx 268 |
— | 30 / 30 days | 1 of 1 | 2006-11-14 | 2006-12-14 | Overdue |