Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| CHANGE HEALTHCARE | Secondary | ||||
| 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 |
|---|---|---|---|---|---|---|
| HYDROXYZ HCL 50MG TAB 50MG 10702001201 · Rx 36688 |
— | 10 / 5 days | 5 of 5 | 2026-04-15 | 2026-04-20 | Overdue |
| CITALOPRAM 20MG TAB-APS 20MG 57664050818 · Rx 33882 |
— | 28 / 28 days | 2 of 3 | 2025-08-01 | 2025-08-29 | Overdue |
| TRAZODONE 150MG TAB 150MG 60505265501 · Rx 33881 |
— | 28 / 28 days | 2 of 3 | 2025-08-01 | 2025-08-29 | Overdue |
| ARIPIPRAZOLE 15MG TAB 15MG 13668021930 · Rx 32746 |
— | 28 / 28 days | 3 of 3 | 2024-03-25 | 2024-04-22 | Overdue |
| LISINOP-HCTZ 20-12.5 TAB 20-12.5 00093103601 · Rx 32481 |
— | 28 / 28 days | 3 of 3 | 2024-03-25 | 2024-04-22 | Overdue |
| INGREZZA 40-80MG CAP 40-80MG 70370204806 · Rx 32350 |
— | 28 / 28 days | 0 of 0 | 2023-07-28 | 2023-08-25 | Completed |
| CABENUVA 600-900 SUS 600-900 49702024015 · Rx 31600 |
— | 6 / 6 days | 0 of 0 | 2022-10-27 | 2022-11-02 | Completed |