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 |
|---|---|---|---|---|---|---|
| NAPROSYN 500MG TAB 500MG 00004631601 · Rx 37013 |
— | 10 / 10 days | 0 of 2 | 2026-07-02 | 2026-07-12 | Completed |
| ALPRAZOLAM 1MG TAB 1MG 59762372104 · Rx 36685 |
— | 1 / 1 days | 0 of 1 | 2026-04-20 | 2026-04-21 | Completed |
| APAP/CODEINE 300-30MG TAB 300-30MG 00093015001 · Rx 36662 |
— | 5 / 5 days | 0 of 0 | 2026-04-09 | 2026-04-14 | Completed |
| PSB SYNTHETIC PRODUCT 00093015001 · Rx 36662 |
— | 5 / 5 days | 0 of 0 | 2026-04-09 | 2026-04-14 | Completed |
| SERTRALINE 100MG TAB 100MG 16714061305 · Rx 34718 |
— | 14 / 14 days | 3 of 3 | 2025-02-05 | 2025-02-19 | Overdue |
| CLOPIDOGREL 75MG TAB 75MG 16729021810 · Rx 33008 |
— | 30 / 30 days | 3 of 3 | 2024-01-29 | 2024-02-28 | Overdue |
| CLOPIDOGREL 75MG TAB 75MG 16729021810 · Rx 32553 |
— | 30 / 30 days | 3 of 3 | 2023-09-14 | 2023-10-14 | Overdue |
| JANUVIA 100MG TAB 100MG 00006027731 · Rx 32015 |
— | 30 / 30 days | 2 of 2 | 2023-04-19 | 2023-05-19 | Overdue |
| LISINOP-HCTZ 20-12.5 TAB 20-12.5 00093103601 · Rx 32014 |
— | 30 / 30 days | 1 of 1 | 2023-04-19 | 2023-05-19 | Overdue |
| SPIRIVA HANDIHLR CAP HANDIHLR 00597007541 · Rx 32012 |
— | 30 / 30 days | 2 of 2 | 2023-04-19 | 2023-05-19 | Overdue |
| ADVAIR DISKU 100/50 MIS 100/50 00173069500 · Rx 32011 |
— | 60 / 30 days | 1 of 1 | 2023-04-19 | 2023-05-19 | Overdue |
| JANUVIA 100MG TAB 100MG 00006027702 · Rx 32009 |
— | 30 / 30 days | 2 of 2 | 2023-04-19 | 2023-05-19 | Overdue |
| LISINOP-HCTZ 20-12.5 TAB 20-12.5 00185015201 · Rx 32008 |
— | 30 / 30 days | 1 of 1 | 2023-04-19 | 2023-05-19 | Overdue |
| SPIRIVA HANDIHLR CAP HANDIHLR 00597007541 · Rx 32006 |
— | 30 / 30 days | 2 of 2 | 2023-04-19 | 2023-05-19 | Overdue |
| ADVAIR DISKU 100/50 MIS 100/50 00173069500 · Rx 32005 |
— | 60 / 30 days | 1 of 1 | 2023-04-19 | 2023-05-19 | Overdue |
| ALBUTEROL HFA AER HFA 69097014260 · Rx 32010 |
— | 6.7 / 28 days | 3 of 3 | 2023-04-19 | 2023-05-17 | Overdue |
| ALBUTEROL HFA AER HFA 00781729685 · Rx 32004 |
— | 6.7 / 28 days | 3 of 3 | 2023-04-19 | 2023-05-17 | Overdue |
| PROMETHAZINE 12.5MG TAB 12.5MG 65162074510 · Rx 32013 |
— | 10 / 5 days | 2 of 2 | 2023-04-19 | 2023-04-24 | Overdue |
| PROMETHAZINE 12.5MG TAB 12.5MG 00603543721 · Rx 32007 |
— | 10 / 5 days | 2 of 2 | 2023-04-19 | 2023-04-24 | Overdue |
| SPRAVATO 56MG DOS SOL 56MG DOS 50458002802 · Rx 31484 |
— | 2 / 28 days | 2 of 5 | 2023-02-17 | 2023-03-17 | Overdue |
| FLUCELVAX QUAD 0.5ML PFS 21-22 2021-22 70461032103 · Rx 31762 |
— | 0.5 / 1 days | 0 of 0 | 2023-01-23 | 2023-01-24 | Completed |
| ACETAMIN 325MG TAB 325MG 51111048893 · Rx 31559 |
— | 100 / 100 days | 0 of 0 | 2022-10-12 | 2023-01-20 | Completed |
| DOCUSATE SOD 100MG CAP 100MG 57896040101 · Rx 31078 |
— | 56 / 28 days | 1 of 1 | 2022-11-24 | 2022-12-22 | Overdue |
| NAPROXEN 500MG TAB 500MG 00143134801 · Rx 31560 |
— | 60 / 30 days | 3 of 3 | 2022-10-12 | 2022-11-11 | Overdue |
| ARMOUR THYRO 30MG TAB 30MG 00456045801 · Rx 31558 |
— | 30 / 30 days | 3 of 3 | 2022-10-12 | 2022-11-11 | Overdue |
| CETIRIZINE HCL 10MG 10MG 00378363701 · Rx 31556 |
— | 30 / 30 days | 3 of 3 | 2022-10-12 | 2022-11-11 | Overdue |
| DIVALPROEX ER 500MG TAB 500MG ER 65862059501 · Rx 31555 |
— | 90 / 30 days | 3 of 3 | 2022-10-12 | 2022-11-11 | Overdue |
| PRENATAL S TAB 00182403901 · Rx 31554 |
— | 30 / 30 days | 3 of 3 | 2022-10-12 | 2022-11-11 | Overdue |
| CALCIUM+D3 600-800 TAB 600-800 96295012823 · Rx 31553 |
— | 30 / 30 days | 3 of 3 | 2022-10-12 | 2022-11-11 | Overdue |
| HALOPERIDOL 5MG/ML INJ 5MG/ML 00143950125 · Rx 31599 |
— | 1 / 14 days | 1 of 1 | 2022-10-27 | 2022-11-10 | Overdue |
| UCARE PEN NEEDLE 29GX12.7 1/2" 29GX12.7 08222710062 · Rx 31557 |
— | 100 / 25 days | 99 of 99 | 2022-10-12 | 2022-11-06 | Overdue |
| FLUARIX QUAD 2015-16 INJ 2015-16 58160090352 · Rx 31576 |
— | 0.5 / 1 days | 0 of 0 | 2022-10-26 | 2022-10-27 | Completed |
| JANUMET 50-1000 TAB 50-1000 00006057761 · Rx 31561 |
— | 30 / 15 days | 3 of 3 | 2022-10-12 | 2022-10-27 | Overdue |
| PAP-ATORVASTATIN 10MG TAB 10MG 60505257808 · Rx 31517 |
— | 30 / 30 days | 3 of 3 | 2022-09-14 | 2022-10-14 | Overdue |
| MULTIVITAMIN CAP 38485012042 · Rx 31516 |
— | 60 / 30 days | 0 of 0 | 2022-09-14 | 2022-10-14 | Completed |
| LYRICA 100MG CAP 100MG 00071101568 · Rx 31515 |
— | 60 / 30 days | 1 of 1 | 2022-09-14 | 2022-10-14 | Overdue |
| VYVANSE 20MG CAP 20MG 59417010210 · Rx 31512 |
— | 30 / 30 days | 0 of 0 | 2022-09-14 | 2022-10-14 | Completed |
| DIAZEPAM 10MG TAB 10MG 00378047701 · Rx 31514 |
— | 15 / 15 days | 3 of 3 | 2022-09-14 | 2022-09-29 | Overdue |
| APAP/CODEINE 300-30MG TAB 300-30MG 00093015001 · Rx 31513 |
— | 6 / 3 days | 0 of 0 | 2022-09-14 | 2022-09-17 | Completed |
| PSB SYNTHETIC PRODUCT 00093015001 · Rx 31513 |
— | 6 / 3 days | 0 of 0 | 2022-09-14 | 2022-09-17 | Completed |
| DONEPEZIL 10MG TAB 10MG 43547027603 · Rx 31467 |
— | 30 / 30 days | 3 of 3 | 2022-07-31 | 2022-08-30 | Overdue |
| SPRAVATO 56MG DOS SOL 56MG DOS 50458002802 · Rx 31221 |
— | 1 / 1 days | 0 of 0 | 2022-07-07 | 2022-07-08 | Completed |
| HALOPER DEC 100MG/ML INJ 100MG/ML 55390041301 · Rx 31220 |
— | 1 / 1 days | 0 of 0 | 2022-07-07 | 2022-07-08 | Completed |
| BUPROPION XL 150MG TAB 150MG XL 10370010103 · Rx 31079 |
— | 28 / 28 days | 1 of 1 | 2022-04-14 | 2022-05-12 | Overdue |
| CYCLOBENZAPR 10MG TAB 10MG 00378075101 · Rx 31087 |
— | 30 / 10 days | 3 of 3 | 2022-04-14 | 2022-04-24 | Overdue |