Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| RELAY TEST PLAN | Primary | ||||
| ARG-PROVIDENCE HEALTH PLA | Secondary | ||||
| M3P BENEFIT PLAN (TEST) | 123001 | 456789001 | 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 |
|---|---|---|---|---|---|---|
| HALOPERIDOL 10MG TAB 10MG 68382008001 · Rx 36659 |
— | 2 / 1 days | 5 of 5 | 2026-04-07 | 2026-04-08 | Overdue |
| RESTASIS 0.05% EMU 0.05% OP 00023916330 · Rx 34527 |
— | 30 / 30 days | 1 of 3 | 2025-11-14 | 2025-12-14 | Overdue |
| VERAPAMIL 100MG ER CAP-APS 100MG ER 00378620101 · Rx 34867 |
— | 30 / 30 days | 3 of 3 | 2025-07-11 | 2025-08-10 | Overdue |
| APS-ABILIFY 10MG TAB 10MG 59148000813 · Rx 34171 |
— | 30 / 30 days | 1 of 3 | 2025-07-11 | 2025-08-10 | Overdue |
| VYVANSE 10MG CAP 10MG 59417010110 · Rx 35648 |
— | 10 / 10 days | 0 of 0 | 2025-07-15 | 2025-07-25 | Completed |
| WELLBUTRIN XL 150MG TAB XL 150MG 00187073090 · Rx 34223 |
— | 5 / 5 days | 3 of 3 | 2025-07-14 | 2025-07-19 | Overdue |
| GABAPENTIN 300MG CAP 300MG 42582011510 · Rx 34580 |
— | 7 / 7 days | 0 of 3 | 2025-05-28 | 2025-06-04 | Completed |
| BUTRANS 10MCG/HR DIS 10MCG/HR 59011075104 · Rx 34835 |
— | 30 / 30 days | 0 of 0 | 2025-02-14 | 2025-03-16 | Completed |
| BUPRENORPHIN POW 63275988401 · Rx 34772 |
— | 1 / 1 days | 3 of 3 | 2025-02-07 | 2025-02-08 | Overdue |
| ATOMOXETINE HCL 100MG CAP 100MG 68462027130 · Rx 34513 |
— | 30 / 30 days | 3 of 3 | 2025-01-06 | 2025-02-05 | Overdue |
| LITHIUM CARB 300MG CAP 300MG 00054252725 · Rx 34482 |
— | 15 / 15 days | 3 of 3 | 2024-12-23 | 2025-01-07 | Overdue |
| SPRAVATO 56MG DOS SOL 56MG DOS 50458002802 · Rx 34433 |
— | 3 / 3 days | 3 of 3 | 2024-12-02 | 2024-12-05 | Overdue |
| VIMPAT 10MG/ML SOL 10MG/ML 00131541070 · Rx 34287 |
— | 30 / 30 days | 3 of 3 | 2024-11-05 | 2024-12-05 | Overdue |
| ALPRAZOLAM 0.25MG TAB 0.25MG 59762371901 · Rx 34371 |
— | 7 / 7 days | 3 of 3 | 2024-11-19 | 2024-11-26 | Overdue |
| ARIPIPRAZOLE 10MG TAB 10MG 16714014301 · Rx 34047 |
— | 7 / 7 days | 1 of 3 | 2024-10-28 | 2024-11-04 | Overdue |
| BUPROPN HCL 150MG XL TAB 150MG XL 68180031906 · Rx 34046 |
— | 7 / 7 days | 1 of 3 | 2024-10-28 | 2024-11-04 | Overdue |
| LISINOPRIL 20MG TAB 20MG 68180098101 · Rx 34045 |
— | 7 / 7 days | 1 of 3 | 2024-10-28 | 2024-11-04 | Overdue |
| HALOPER DEC 100MG/ML INJ 100MG/ML 00703713301 · Rx 34208 |
— | 5 / 5 days | 3 of 3 | 2024-10-28 | 2024-11-02 | Overdue |
| OLANZAPINE 10MG TAB 10MG 43598016630 · Rx 34044 |
— | 7 / 7 days | 3 of 3 | 2024-09-12 | 2024-09-19 | Overdue |
| ZYPREXA RELP 300MG INJ 300MG 00002763611 · Rx 33154 |
— | 1 / 1 days | 5 of 5 | 2024-03-04 | 2024-03-05 | Overdue |
| PNEUMOVAX 23 25MCG/.5 INJ 25/0.5 00006494300 · Rx 33153 |
— | 0.5 / 1 days | 0 of 0 | 2024-03-04 | 2024-03-05 | Completed |
| ENGERIX-B 20MCG/ML INJ 20MCG/ML 58160082148 · Rx 33152 |
— | 0.5 / 1 days | 0 of 0 | 2024-03-04 | 2024-03-05 | Completed |
| FLUAD QUADRI 2023-24 INJ 2023-24 70461012303 · Rx 33151 |
— | 0.5 / 1 days | 0 of 0 | 2024-03-04 | 2024-03-05 | Completed |
| MODERNA COVID BIVAL BSTR 0.5ML BA4/BA5 80777028299 · Rx 33150 |
— | 0.5 / 1 days | 0 of 0 | 2024-03-04 | 2024-03-05 | Completed |
| SPRAVATO 84MG DOS SOL 84MG DOS 50458002803 · Rx 32700 |
— | 3 / 1 days | 3 of 3 | 2023-10-18 | 2023-10-19 | Overdue |
| TRIAM/HCTZ 37.5-25 CAP 37.5-25 00378253701 · Rx 32430 |
— | 3 / 3 days | 5 of 5 | 2023-07-28 | 2023-07-31 | Overdue |
| AUSTEDO 12MG TAB 12MG 68546017260 · Rx 32323 |
— | 1 / 1 days | 1 of 1 | 2023-07-27 | 2023-07-28 | Overdue |
| VENLAFAXINE 100MG TAB 100MG 65162030509 · Rx 32048 |
— | 56 / 28 days | 0 of 0 | 2023-04-25 | 2023-05-23 | Completed |
| BUSPIRONE 10MG TAB 10MG 00093005401 · Rx 32047 |
— | 84 / 28 days | 0 of 0 | 2023-04-25 | 2023-05-23 | Completed |
| ARIPIPRAZOLE 10MG TAB 10MG 00904651161 · Rx 32046 |
— | 28 / 28 days | 0 of 0 | 2023-04-25 | 2023-05-23 | Completed |
| VANCOCIN HCL 250MG CAP 250MG 66593312602 · Rx 31893 |
— | 20 / 10 days | 0 of 0 | 2023-03-14 | 2023-03-24 | Completed |