Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| PRIVATE | PR | 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 |
|---|---|---|---|---|---|---|
| CITALOPRAM 10MG TAB 10MG 00378623101 · Rx 30236 |
— | 30 / 30 days | 12 of 12 | 2021-04-20 | 2021-05-20 | Overdue |
| PURPLE CANDY 00000012255 · Rx 26995 |
— | 7 / 7 days | 0 of 0 | 2015-08-17 | 2015-08-24 | Completed |
| BROWN CANDY CANDY 99999999555 · Rx 26939 |
— | 28 / 28 days | 0 of 0 | 2015-07-23 | 2015-08-20 | Completed |
| YELLOW CANDY 0 00010101010 · Rx 26938 |
— | 56 / 28 days | 0 of 0 | 2015-07-23 | 2015-08-20 | Completed |
| PINK CANDY 10254125212 · Rx 26937 |
— | 28 / 28 days | 0 of 0 | 2015-07-23 | 2015-08-20 | Completed |
| BROWN CANDY CANDY 99999999555 · Rx 26984 |
— | 7 / 7 days | 0 of 0 | 2015-08-10 | 2015-08-17 | Completed |
| PINK CANDY 10254125212 · Rx 26983 |
— | 7 / 7 days | 0 of 0 | 2015-08-10 | 2015-08-17 | Completed |
| YELLOW CANDY 0 00010101010 · Rx 26982 |
— | 14 / 7 days | 0 of 0 | 2015-08-10 | 2015-08-17 | Completed |
| ORANGE CANDY 45678912301 · Rx 26981 |
— | 7 / 7 days | 1 of 1 | 2015-08-10 | 2015-08-17 | Overdue |
| ALPRAZOLAM 1MG TAB 1MG 59762372101 · Rx 24824 |
— | 112 / 28 days | 0 of 0 | 2012-12-27 | 2013-01-24 | Completed |
| HYDROCO/APAP 5-325MG TAB 5-325MG 00406036501 · Rx 24823 |
— | 112 / 28 days | 0 of 0 | 2012-12-27 | 2013-01-24 | Completed |
| MELATONIN 3MG TAB 3MG 51991001406 · Rx 24822 |
— | 56 / 28 days | 0 of 0 | 2012-12-27 | 2013-01-24 | Completed |
| METHYLPHENIDATE 10MG TAB 10MG 00406114401 · Rx 24821 |
— | 112 / 28 days | 0 of 0 | 2012-12-27 | 2013-01-24 | Completed |
| ZOLPIDEM TAR 10MG TAB 10MG 60505260501 · Rx 24825 |
— | 28 / 1 days | 0 of 0 | 2012-12-27 | 2012-12-28 | Completed |