Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| HARDSHIP ASSISTANCE | Primary | ||||
| EXPRESS SCRIPTS INSURANCE | 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 |
|---|---|---|---|---|---|---|
| ACETAMIN 500MG TAB 500MG 00182845389 · Rx 36266 |
— | 30 / 30 days | 4 of 4 | 2025-12-03 | 2026-01-02 | Overdue |
| INVEGA TRINZ 410MG INJ 410MG 50458060701 · Rx 36270 |
— | 20 / 20 days | 4 of 4 | 2025-12-04 | 2025-12-24 | Overdue |
| INVEGA 3MG TAB 3MG 50458055010 · Rx 36264 |
— | 20 / 20 days | 2 of 2 | 2025-12-03 | 2025-12-23 | Overdue |
| INVEGA 1.5MG TAB 1.5MG 50458055401 · Rx 36263 |
— | 10 / 10 days | 1 of 1 | 2025-12-03 | 2025-12-13 | Overdue |
| LISINOPRIL 10MG TAB 10MG 68180098003 · Rx 36262 |
— | 10 / 10 days | 2 of 2 | 2025-12-03 | 2025-12-13 | Overdue |
| LISINOPRIL 10MG TAB 10MG 68180098003 · Rx 36261 |
— | 10 / 10 days | 2 of 2 | 2025-12-03 | 2025-12-13 | Overdue |
| TRAZODONE 150MG TAB 150MG 60505265501 · Rx 36203 |
— | 7 / 7 days | 3 of 3 | 2025-11-21 | 2025-11-28 | Overdue |
| DIP/TET PED 6.7-5LF INJ 6.7-5LF 49281027810 · Rx 35061 |
— | 0.5 / 1 days | 0 of 0 | 2025-03-12 | 2025-03-13 | Completed |
| NYSTAT/TRIAM CRE 00472015060 · Rx 32561 |
— | 60 / 15 days | 2 of 2 | 2023-09-21 | 2023-10-06 | Overdue |
| IBUPROFEN 100/5ML SUS 100/5ML 00472200216 · Rx 31661 |
— | 30 / 30 days | 1 of 3 | 2023-05-17 | 2023-06-16 | Overdue |
| ARISTADA 882MG/3.2ML INJ 882MG/3 65757040303 · Rx 31701 |
— | 3.2 / 28 days | 0 of 0 | 2022-12-20 | 2023-01-17 | Completed |
| SUBLOCADE 300/1.5 INJ 300/1.5 12496030001 · Rx 31699 |
— | 1.5 / 28 days | 0 of 0 | 2022-12-20 | 2023-01-17 | Completed |
| RISPERDAL CONSTA 12.5MG INJ 12.5MG 50458030911 · Rx 31704 |
— | 1 / 14 days | 0 of 0 | 2022-12-20 | 2023-01-03 | Completed |
| HALOPERIDOL 5MG/ML INJ 5MG/ML 00143950125 · Rx 31698 |
— | 1 / 7 days | 0 of 0 | 2022-12-20 | 2022-12-27 | Completed |
| CABENUVA 600-900 SUS 600-900 49702024015 · Rx 31700 |
— | 6 / 6 days | 0 of 0 | 2022-12-20 | 2022-12-26 | Completed |
| ADMIN-ABILIFY MAINTENA 88888000101 · Rx 31703 |
— | 1 / 1 days | 0 of 0 | 2022-12-20 | 2022-12-21 | Completed |
| ZYPREXA RELP 405MG INJ 405MG 00002763711 · Rx 31702 |
— | 1 / 1 days | 0 of 0 | 2022-12-20 | 2022-12-21 | Completed |