Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| AETNA | TEST | TEST | Secondary | ||
| PRIVATE | PR | Secondary | |||
| SAMPLES | Secondary | ||||
| RELAY TEST PLAN COPAY | Secondary | ||||
| RELAY TEST CAPTURED RESP | Secondary | ||||
| RELAY TEST PLAN | 1234 | 456789 | 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 |
|---|---|---|---|---|---|---|
| TOPIRAMATE 200MG TAB 200MG 62756071286 · Rx 37098 |
— | 10 / 10 days | 1 of 1 | 2026-08-04 | 2026-08-14 | Overdue |
| TOPIRAMATE ER 150MG CAP ER 150MG 00832107530 · Rx 37061 |
— | 7 / 7 days | 5 of 5 | 2026-07-23 | 2026-07-30 | Overdue |
| FUROSEMIDE 20MG TAB 20MG 63304062401 · Rx 36953 |
— | 30 / 30 days | 0 of 0 | 2026-06-17 | 2026-07-17 | Completed |
| ZYPREXA RELP 405MG INJ 405MG 00002763711 · Rx 36377 |
— | 1 / 28 days | 3 of 5 | 2026-06-17 | 2026-07-15 | Overdue |
| BAND AID MIS 08137104226 · Rx 35926 |
— | 20 / 20 days | 4 of 5 | 2026-06-17 | 2026-07-07 | Overdue |
| HALDOL 0.5MG TAB 0.5MG 00045024060 · Rx 36928 |
— | 10 / 10 days | 1 of 1 | 2026-06-10 | 2026-06-20 | Overdue |
| FLUOXETINE 20MG CAP 20MG 65862019399 · Rx 36933 |
— | 1 / 1 days | 0 of 0 | 2026-06-10 | 2026-06-11 | Completed |
| APAP/CODEINE 300-30MG TAB 300-30MG 00093015001 · Rx 36870 |
— | 5 / 5 days | 0 of 0 | 2026-06-01 | 2026-06-06 | Completed |
| PSB SYNTHETIC PRODUCT 00093015001 · Rx 36870 |
— | 5 / 5 days | 0 of 0 | 2026-06-01 | 2026-06-06 | Completed |
| HALDOL 10MG TAB 10MG 00045024660 · Rx 35725 |
— | 15 / 15 days | 0 of 1 | 2026-04-07 | 2026-04-22 | Completed |
| LEXAPRO 10MG TAB 10MG 00456201001 · Rx 36446 |
— | 15 / 15 days | 1 of 1 | 2026-01-30 | 2026-02-14 | Overdue |
| SALINE MIST 0.65% SPR 0.65% 00536250676 · Rx 36445 |
— | 44 / 5 days | 99 of 99 | 2026-01-30 | 2026-02-04 | Overdue |
| INVEGA 1.5MG TAB 1.5MG 50458055401 · Rx 36373 |
— | 1 / 1 days | 8 of 9 | 2026-01-30 | 2026-01-31 | Overdue |
| ALCOHOL PADS 00000001104 · Rx 35752 |
— | 100 / 100 days | 0 of 0 | 2025-07-31 | 2025-11-08 | Completed |
| LANCETS MIS 38415010028 · Rx 35930 |
— | 100 / 25 days | 1 of 1 | 2025-09-12 | 2025-10-07 | Overdue |
| FLONASE 0.05% SPR 0.05% 00173045301 · Rx 35929 |
— | 16 / 16 days | 1 of 1 | 2025-09-12 | 2025-09-28 | Overdue |
| SALINE MIST 0.65% SPR 0.65% 00536250676 · Rx 35928 |
— | 44 / 15 days | 1 of 1 | 2025-09-12 | 2025-09-27 | Overdue |
| HIBICLENS 4% LIQ 4% 00234057504 · Rx 35927 |
— | 118 / 10 days | 5 of 5 | 2025-09-12 | 2025-09-22 | Overdue |
| CHANTIX 0.5& 1MG PAK 0.5& 1MG 00069047103 · Rx 35723 |
— | 53 / 53 days | 1 of 1 | 2025-07-30 | 2025-09-21 | Overdue |
| LISINOP-HCTZ 10-12.5 TAB 10-12.5 00093103501 · Rx 35931 |
XFer To RPH1 @ GENOA HEALTHCARE, LLC - 791 CHAMBERS RD RM 152, AURORA, | 7 / 7 days | 1 of 1 | 2025-09-12 | 2025-09-19 | Overdue |
| WELLBUTRIN XL 150MG TAB XL 150MG 00187073030 · Rx 35724 |
— | 10 / 5 days | 3 of 3 | 2025-07-30 | 2025-08-04 | Overdue |
| LUMIGAN 0.01% SOL 0.01% OP 00023320503 · Rx 34725 |
— | 2.5 / 2 days | 2 of 3 | 2025-07-11 | 2025-07-13 | Overdue |
| COTTON BALLS MIS 87701024760 · Rx 35328 |
— | 300 / 25 days | 3 of 3 | 2025-06-05 | 2025-06-30 | Overdue |
| STERILE WATER FOR INJ WATER 00409488710 · Rx 35329 |
— | 10 / 10 days | 0 of 0 | 2025-06-13 | 2025-06-23 | Completed |
| LANTUS 100U/ML INJ 100/ML 00088222033 · Rx 34736 |
— | 10 / 10 days | 0 of 0 | 2025-06-05 | 2025-06-15 | Completed |
| LISINOPRIL 20MG TAB 20MG 68180098101 · Rx 34004 |
— | 7 / 7 days | 0 of 5 | 2025-06-05 | 2025-06-12 | Completed |
| INVEGA TRINZ 819MG INJ 819MG 50458060901 · Rx 34048 |
— | 2.625 / 84 days | 2 of 3 | 2024-12-17 | 2025-03-11 | Overdue |
| ASPIRIN LOW 81MG EC TAB 81MG EC 49483048110 · Rx 34935 |
— | 7 / 7 days | 3 of 3 | 2025-03-03 | 2025-03-10 | Overdue |
| IMMUNE GLOBU HUMAN INJ HUMAN 52769057622 · Rx 34968 |
— | 2 / 2 days | 0 of 0 | 2025-03-06 | 2025-03-08 | Completed |
| PNEUMOVAX 23 25MCG/.5 INJ 25/0.5 00006494300 · Rx 34970 |
— | 0.5 / 1 days | 0 of 0 | 2025-03-06 | 2025-03-07 | Completed |
| PFIZER 5-11Y 2024-25 INJ 2024-25 59267443801 · Rx 34969 |
— | 0.3 / 1 days | 0 of 0 | 2025-03-06 | 2025-03-07 | Completed |
| ASPIR-LOW 81MG EC TAB 81MG EC 00904770418 · Rx 34846 |
— | 15 / 7 days | 3 of 3 | 2025-02-19 | 2025-02-26 | Overdue |
| SYMBICORT 80-4.5 AER 80-4.5 00186037220 · Rx 34633 |
— | 10.2 / 30 days | 3 of 3 | 2025-01-22 | 2025-02-21 | Overdue |
| PROPRANOLOL 10MG TAB 10MG 00591555410 · Rx 34631 |
— | 60 / 30 days | 3 of 3 | 2025-01-22 | 2025-02-21 | Overdue |
| CHLOR GLUC 4% LIQ 4% 52380127204 · Rx 34551 |
— | 118 / 39 days | 3 of 3 | 2025-01-09 | 2025-02-17 | Overdue |
| ALCOHOL PADS 00000001104 · Rx 34625 |
— | 100 / 25 days | 3 of 3 | 2025-01-22 | 2025-02-16 | Overdue |
| VENTOLIN HFA AER 00173068224 · Rx 34630 |
— | 8 / 15 days | 3 of 3 | 2025-01-22 | 2025-02-06 | Overdue |
| ASPIRIN 81MG EC TAB 81MG EC 00182106105 · Rx 34643 |
— | 15 / 7 days | 3 of 3 | 2025-01-24 | 2025-01-31 | Overdue |
| PAP-INVEGA SUST 117/0.75 INJ 117/0.75 50458056201 · Rx 34377 |
— | 0.75 / 28 days | 0 of 0 | 2024-12-17 | 2025-01-14 | Completed |
| BUPROPN HCL 150MG XL TAB 150MG XL 68180031906 · Rx 34003 |
— | 7 / 7 days | 1 of 5 | 2024-12-30 | 2025-01-06 | Overdue |
| CHLORPROMAZINE 100MG TAB 100MG 00832030300 · Rx 34447 |
— | 14 / 7 days | 3 of 3 | 2024-12-17 | 2024-12-24 | Overdue |
| ALLOPURINOL 100MG TAB 100MG 00378013701 · Rx 34446 |
— | 7 / 7 days | 3 of 3 | 2024-12-17 | 2024-12-24 | Overdue |
| OLANZAPINE 10MG TAB 10MG 43598016630 · Rx 34002 |
— | 7 / 7 days | 2 of 5 | 2024-11-21 | 2024-11-28 | Overdue |
| INVEGA TRINZ 819MG INJ 819MG 50458060901 · Rx 34005 |
— | 2.625 / 84 days | 0 of 0 | 2024-08-30 | 2024-11-22 | Completed |
| FLULAVAL PFS 2024-25 2024-25 19515081052 · Rx 34006 |
— | 0.5 / 1 days | 0 of 0 | 2024-08-30 | 2024-08-31 | Completed |
| SPRAVATO 84MG DOS SOL 84MG DOS 50458002803 · Rx 32703 |
— | 3 / 1 days | 3 of 3 | 2023-10-18 | 2023-10-19 | Overdue |
| INGREZZA 40-80MG CAP 40-80MG 70370204806 · Rx 32339 |
— | 28 / 28 days | 0 of 0 | 2023-07-28 | 2023-08-25 | Completed |
| NORETH/ETHIN FE CHW FE 00378730853 · Rx 32373 |
— | 7 / 7 days | 4 of 5 | 2023-08-08 | 2023-08-15 | Overdue |
| IODINE 2% MILD TIN 2% MILD 00395121316 · Rx 32428 |
— | 480 / 7 days | 0 of 0 | 2023-08-01 | 2023-08-08 | Completed |
| SAM-ABILIFY 10MG TAB #30 10MG 59148000856 · Rx 31638 |
— | 30 / 30 days | 0 of 0 | 2022-11-17 | 2022-12-17 | Completed |
| NAPROXEN 220MG TAB 220MG 00904523059 · Rx 31637 |
— | 60 / 30 days | 3 of 3 | 2022-11-17 | 2022-12-17 | Overdue |
| OMEPRAZOLE 40MG CR CAP 40MG 60505014600 · Rx 31636 |
— | 30 / 30 days | 0 of 0 | 2022-11-17 | 2022-12-17 | Completed |
| MULTIVITAMIN/ FE /IRON 74312001580 · Rx 31633 |
— | 30 / 30 days | 3 of 3 | 2022-11-16 | 2022-12-16 | Overdue |