Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| MED D CAREMARK | DCA | Secondary | |||
| EMPLOYEE PURCHASES(INACTI | Secondary | ||||
| HARDSHIP ASSISTANCE | Secondary | ||||
| PRIVATE | PR | Secondary | |||
| RELAY TEST PLAN | 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 |
|---|---|---|---|---|---|---|
| IBUPROFEN 100/5ML SUS 100/5ML 00472200216 · Rx 35307 |
— | 30 / 30 days | 1 of 3 | 2025-11-18 | 2025-12-18 | Overdue |
| BUPRENORPHINE 8MG SUB 8MG 00378092493 · Rx 34706 |
— | 1 / 1 days | 1 of 1 | 2025-02-04 | 2025-02-05 | Overdue |
| FLONASE 0.05% SPR 0.05% 00173045301 · Rx 34501 |
— | 16 / 16 days | 3 of 3 | 2024-12-30 | 2025-01-15 | Overdue |
| HYDROCHLOROT 25MG TAB 25MG 00172208380 · Rx 33164 |
— | 30 / 30 days | 2 of 2 | 2024-03-06 | 2024-04-05 | Overdue |
| ILETIN II RG U100PORK INJ U100PORK 00002821101 · Rx 33181 |
— | 1 / 1 days | 0 of 0 | 2024-03-07 | 2024-03-08 | Completed |
| JALYN CAP 00173080913 · Rx 30313 |
— | 1 / 1 days | 2 of 2 | 2021-05-20 | 2021-05-21 | Overdue |
| HALOBETASOL 0.05% OIN 0.05% 00168035650 · Rx 30006 |
— | 10 / 10 days | 1 of 1 | 2020-11-09 | 2020-11-19 | Overdue |
| ASACOL 400MG EC TAB 400MG DR 00149075215 · Rx 30007 |
— | 5 / 5 days | 1 of 1 | 2020-11-09 | 2020-11-14 | Overdue |
| DUTASTER/TAMSULOS 0.5-0.4MG CP 0.5-0.4 10370028009 · Rx 29858 |
— | 10 / 10 days | 0 of 0 | 2020-06-17 | 2020-06-27 | Completed |
| 340B-CITALOPRAM 10MG TAB 10MG 00185037101 · Rx 29687 |
— | 90 / 90 days | 0 of 0 | 2019-12-12 | 2020-03-11 | Completed |
| ATORVASTATIN 20MG TAB 20MG 00591377519 · Rx 29684 |
— | 60 / 30 days | 3 of 3 | 2019-12-12 | 2020-01-11 | Overdue |
| ZOLPIDEM 10MG TAB 10MG 00093007401 · Rx 29688 |
— | 30 / 30 days | 5 of 5 | 2019-12-07 | 2020-01-06 | Overdue |
| SERTRALINE 100MG TAB 100MG 00378418801 · Rx 29683 |
— | 30 / 30 days | 2 of 2 | 2019-12-05 | 2020-01-04 | Overdue |
| ASPIRIN 81MG EC TAB 81MG EC 00536100441 · Rx 29685 |
— | 30 / 30 days | 3 of 3 | 2019-11-30 | 2019-12-30 | Overdue |
| LISINOPRIL 2.5MG TAB 2.5MG 00172375760 · Rx 29686 |
— | 45 / 23 days | 0 of 0 | 2019-12-05 | 2019-12-28 | Completed |
| 1234564680 1234564680 · Rx 29530 |
— | 3 / 3 days | 3 of 3 | 2019-06-24 | 2019-06-27 | Overdue |
| JELLYBEAN 50505050505 · Rx 29529 |
— | 60 / 60 days | 10 of 10 | 2019-04-20 | 2019-06-19 | Overdue |
| 3M TEGADERM 4" X 4" MIS 4"X4" 08333900020 · Rx 29339 |
— | 10 / 10 days | 0 of 1 | 2018-06-29 | 2018-07-09 | Completed |
| TUMS E-X 750MG CHW 750MG 00135017808 · Rx 29338 |
— | 75 / 75 days | 2 of 2 | 2018-02-08 | 2018-04-24 | Overdue |
| JELLYBEAN 50505050505 · Rx 28995 |
— | 60 / 60 days | 0 of 0 | 2017-05-15 | 2017-07-14 | Completed |
| ILETIN II RG U100PORK INJ U100PORK 00002821101 · Rx 28994 |
— | 30 / 30 days | 2 of 2 | 2017-05-15 | 2017-06-14 | Overdue |
| IBUPROFEN 200MG TAB 200MG 00182103901 · Rx 28693 |
— | 50 / 50 days | 0 of 0 | 2017-03-20 | 2017-05-09 | Completed |
| DANTRIUM 25MG CAP 25MG 42023012401 · Rx 28402 |
— | 90 / 90 days | 3 of 3 | 2017-01-04 | 2017-04-04 | Overdue |
| CANDY CORN 12378945612 · Rx 28691 |
— | 10 / 10 days | 0 of 0 | 2017-03-20 | 2017-03-30 | Completed |
| EYE DROPS 0.05% OP SOL 0.05% OP 24385007501 · Rx 28692 |
— | 1 / 1 days | 0 of 0 | 2017-03-20 | 2017-03-21 | Completed |
| OXAZEPAM 15MG CAP 15MG 00228206910 · Rx 28478 |
— | 90 / 30 days | 3 of 3 | 2017-02-09 | 2017-03-11 | Overdue |
| 1234564680 1234564680 · Rx 27962 |
— | 30 / 30 days | 0 of 0 | 2016-07-29 | 2016-08-28 | Completed |
| NICODERM CQ 14MG/24 DIS 14MG/24H 00766146020 · Rx 27833 |
— | 60 / 60 days | 0 of 0 | 2016-06-09 | 2016-08-08 | Completed |
| RED CANDY 92520001500 · Rx 27837 |
— | 30 / 30 days | 0 of 0 | 2016-06-09 | 2016-07-09 | Completed |
| ACETAMIN 325MG TAB 325MG 51111048893 · Rx 27824 |
— | 30 / 30 days | 0 of 0 | 2016-06-09 | 2016-07-09 | Completed |
| IBU 800MG TAB 800MG 49884046901 · Rx 27823 |
— | 30 / 30 days | 0 of 0 | 2016-06-09 | 2016-07-09 | Completed |
| BANDAID JJ BANDAID JJ · Rx 27822 |
— | 20 / 20 days | 0 of 0 | 2016-06-09 | 2016-06-29 | Completed |
| EYE IRRIGATI OP SOL OP 00536090197 · Rx 27835 |
— | 15 / 15 days | 0 of 0 | 2016-06-09 | 2016-06-24 | Completed |
| CANTIL TAB 25MG 00068003701 · Rx 27827 |
— | 15 / 15 days | 0 of 0 | 2016-06-09 | 2016-06-24 | Completed |
| EYE DROPS 0.05% OP SOL 0.05% OP 24385007501 · Rx 27834 |
— | 12 / 12 days | 0 of 0 | 2016-06-09 | 2016-06-21 | Completed |
| HYDROXYCHLOR 200MG TAB 200MG 00591069801 · Rx 27831 |
— | 12 / 12 days | 0 of 0 | 2016-06-09 | 2016-06-21 | Completed |
| ENSURE STRWBERY LIQ STRWBERY 70074050649 · Rx 27825 |
— | 12 / 12 days | 0 of 0 | 2016-06-09 | 2016-06-21 | Completed |
| PINK BISM 527/30ML SUS 527/30ML 87701053728 · Rx 27836 |
— | 10 / 10 days | 0 of 0 | 2016-06-09 | 2016-06-19 | Completed |
| CHILD ASA 81MG CHW 81MG 00182142095 · Rx 27830 |
— | 10 / 10 days | 0 of 0 | 2016-06-09 | 2016-06-19 | Completed |
| CHERRY SYP 00395266216 · Rx 27829 |
— | 10 / 10 days | 0 of 0 | 2016-06-09 | 2016-06-19 | Completed |
| SALINE MIST 0.65% SPR 0.65% 00536250676 · Rx 27821 |
— | 10 / 10 days | 0 of 0 | 2016-06-09 | 2016-06-19 | Completed |
| BLOOD DRAW BLOOD DRAW · Rx 27838 |
— | 1 / 1 days | 0 of 0 | 2016-06-09 | 2016-06-10 | Completed |
| FLUTICASONE 0.005% OIN 0.005% 00713063260 · Rx 27828 |
— | 1 / 1 days | 0 of 0 | 2016-06-09 | 2016-06-10 | Completed |
| CANE-ALUM CANE-ALUM · Rx 27826 |
— | 1 / 1 days | 0 of 0 | 2016-06-09 | 2016-06-10 | Completed |
| B-6 100MG TAB 100MG 37205054378 · Rx 27470 |
— | 30 / 30 days | 2 of 2 | 2016-02-22 | 2016-03-23 | Overdue |
| BANDAGES BANDAGES · Rx 27469 |
— | 30 / 30 days | 0 of 0 | 2016-02-22 | 2016-03-23 | Completed |
| CANDY CORN 12378945612 · Rx 27200 |
— | 100 / 100 days | 0 of 0 | 2015-10-21 | 2016-01-29 | Completed |
| ENSURE PLUS VANILLA LIQ VANILLA 70074040707 · Rx 27240 |
— | 30 / 30 days | 0 of 0 | 2015-11-05 | 2015-12-05 | Completed |
| ENSURE CHOCOLAT LIQ CHOCOLAT 70074050463 · Rx 27232 |
— | 20 / 20 days | 0 of 0 | 2015-11-03 | 2015-11-23 | Completed |
| 1234564680 1234564680 · Rx 27201 |
— | 30 / 30 days | 0 of 0 | 2015-10-21 | 2015-11-20 | Completed |
| ABILIFY 30MG TAB 30MG 59148001113 · Rx 26950 |
— | 30 / 30 days | 0 of 0 | 2015-07-29 | 2015-08-28 | Completed |
| BROWN M&M 24230492039 · Rx 26731 |
— | 100 / 100 days | 0 of 0 | 2015-05-13 | 2015-08-21 | Completed |
| FAMOTIDINE 40MG TAB 40MG 00378304001 · Rx 26847 |
— | 30 / 30 days | 0 of 0 | 2015-07-02 | 2015-08-01 | Completed |
| UCARE PEN NEEDLE 29G/12.7 1/2" 29GX1/2" 08222095121 · Rx 26675 |
— | 100 / 100 days | 0 of 0 | 2015-04-22 | 2015-07-31 | Completed |
| CALCIUM 500+ D CHW /D 51645082906 · Rx 26733 |
— | 60 / 60 days | 0 of 0 | 2015-05-13 | 2015-07-12 | Completed |
| TAIL CLOSURE MIS 00003175635 · Rx 26848 |
— | 5 / 5 days | 0 of 0 | 2015-07-02 | 2015-07-07 | Completed |
| CANDY 12312312300 · Rx 26849 |
— | 1 / 1 days | 0 of 0 | 2015-07-02 | 2015-07-03 | Completed |
| SAM-ABILIFY 5MG TAB #7 5MG 59148000755 · Rx 26732 |
— | 30 / 30 days | 0 of 0 | 2015-05-13 | 2015-06-12 | Completed |
| X-VIATE 40% CRE 40% 58980062510 · Rx 26730 |
— | 30 / 30 days | 0 of 0 | 2015-05-13 | 2015-06-12 | Completed |
| GUAIFENESIN 100/5ML SOL 100/5ML 00121074404 · Rx 26729 |
— | 30 / 30 days | 0 of 0 | 2015-05-13 | 2015-06-12 | Completed |
| CHEWABLE VITE (RUGBY) CHILDRNS 00536344801 · Rx 26728 |
— | 30 / 30 days | 0 of 0 | 2015-05-13 | 2015-06-12 | Completed |
| DOK PLUS 8.6MG/50MG TAB 8.6-50MG 00904564360 · Rx 26727 |
— | 30 / 30 days | 0 of 0 | 2015-05-13 | 2015-06-12 | Completed |
| FLUTICASONE 50MCG SPR 50MCG 00054327099 · Rx 26701 |
— | 16 / 16 days | 0 of 0 | 2015-05-05 | 2015-05-21 | Completed |
| NEFAZODONE 150MG TAB 150MG 00093711306 · Rx 26674 |
— | 60 / 20 days | 0 of 0 | 2015-04-22 | 2015-05-12 | Completed |
| 10 DOLLAR ENROLLMENT 22212132135 · Rx 26690 |
— | 1 / 1 days | 0 of 0 | 2015-04-29 | 2015-04-30 | Completed |
| TYLENOL FLU NO-DROW TAB NO-DROW 00045084112 · Rx 26535 |
— | 30 / 30 days | 0 of 0 | 2015-02-13 | 2015-03-15 | Completed |
| PENICILLN VK 500MG TAB 500MG 00781165510 · Rx 26534 |
— | 30 / 30 days | 2 of 2 | 2015-02-13 | 2015-03-15 | Overdue |