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 |
|---|---|---|---|---|---|---|
| CHOCOLATE CANDY 01000000010 · Rx 29528 |
— | 20 / 3 days | 1 of 1 | 2019-06-24 | 2019-06-27 | Overdue |
| JELLYBEAN 50505050505 · Rx 29526 |
— | 6 / 6 days | 6 of 6 | 2019-06-20 | 2019-06-26 | Overdue |
| GABAPENTIN POW 63370009925 · Rx 29527 |
— | 3 / 3 days | 2 of 2 | 2019-06-20 | 2019-06-23 | Overdue |
| PAP-ABILIFY 2MG TAB 2MG 59148000613 · Rx 29305 |
— | 30 / 30 days | 0 of 0 | 2017-09-11 | 2017-10-11 | Completed |
| ARIPIPRAZOLE 2MG TAB 2MG 65162089603 · Rx 29304 |
— | 30 / 30 days | 0 of 0 | 2017-09-11 | 2017-10-11 | Completed |
| BEELITH TAB 00486113201 · Rx 28702 |
— | 60 / 60 days | 0 of 0 | 2017-03-23 | 2017-05-22 | Completed |
| CANDY 12312312300 · Rx 28703 |
— | 50 / 50 days | 0 of 0 | 2017-03-23 | 2017-05-12 | Completed |
| BUMETANIDE 1MG TAB 1MG 00378037001 · Rx 28701 |
— | 30 / 30 days | 0 of 0 | 2017-03-23 | 2017-04-22 | Completed |
| QUASENSE TAB 52544096691 · Rx 26512 |
— | 400 / 400 days | 0 of 0 | 2015-02-05 | 2016-03-11 | Completed |
| SEROPHENE 50MG TAB 50MG 44087809006 · Rx 26513 |
— | 399 / 399 days | 0 of 0 | 2015-02-05 | 2016-03-10 | Completed |
| TRI-NORINYL 28 TAB 28 52544027428 · Rx 26510 |
— | 200 / 200 days | 0 of 0 | 2015-02-05 | 2015-08-24 | Completed |
| PENICILLN VK 500MG TAB 500MG 00781165501 · Rx 26492 |
— | 200 / 200 days | 0 of 0 | 2015-01-28 | 2015-08-16 | Completed |
| BENAZEP/HCTZ 20-25MG TAB 20-25MG 00185027701 · Rx 26509 |
— | 100 / 100 days | 0 of 0 | 2015-02-05 | 2015-05-16 | Completed |
| 10 DOLLAR ENROLLMENT 22212132135 · Rx 26691 |
— | 1 / 1 days | 12 of 12 | 2015-04-29 | 2015-04-30 | Overdue |
| CODAL-DH SYP 60258077016 · Rx 26511 |
— | 30 / 30 days | 0 of 0 | 2015-02-05 | 2015-03-07 | Completed |