Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| RELAY TEST PLAN | Primary | ||||
| COLORADO MEDICAID 1 | Secondary | ||||
| MAX FAIR PRICING PLAN | NEGATIVE TESTING | 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 |
|---|---|---|---|---|---|---|
| COUMADIN 10MG TAB 10MG 00056017475 · Rx 35489 |
— | 7 / 7 days | 3 of 3 | 2025-06-25 | 2025-07-02 | Overdue |
| ALPRAZOLAM 2MG ER TAB 2MG ER 65162081206 · Rx 34497 |
— | 7 / 1 days | 3 of 3 | 2024-12-27 | 2024-12-28 | Overdue |
| INGREZZA 40MG CAP 40MG 70370204001 · Rx 32334 |
— | 1 / 1 days | 1 of 4 | 2024-07-23 | 2024-07-24 | Overdue |
| JTEST-TRAZODONE 50MG TAB 50MG 50111043303 · Rx 32116 |
— | 30 / 30 days | 3 of 5 | 2024-04-16 | 2024-05-16 | Overdue |
| DAILY MULTI TAB 30768000747 · Rx 32129 |
— | 28 / 28 days | 95 of 99 | 2024-03-01 | 2024-03-29 | Overdue |
| SPRAVATO 84MG DOS SOL 84MG DOS 50458002803 · Rx 32708 |
— | 3 / 1 days | 0 of 2 | 2024-01-17 | 2024-01-18 | Completed |
| SPRAVATO 56MG DOS SOL 56MG DOS 50458002802 · Rx 32707 |
— | 3 / 1 days | 3 of 3 | 2023-10-19 | 2023-10-20 | Overdue |
| LISINOP-HCTZ 20-12.5 TAB 20-12.5 00172503460 · Rx 32113 |
— | 21 / 21 days | 1 of 5 | 2023-08-29 | 2023-09-19 | Overdue |
| CETIRIZINE HCL 10MG 10MG 00378363701 · Rx 32115 |
— | 14 / 14 days | 2 of 6 | 2023-08-29 | 2023-09-12 | Overdue |
| AMLODIPINE 5MG TAB 5MG 69097083705 · Rx 32523 |
— | 1 / 1 days | 0 of 0 | 2023-09-08 | 2023-09-09 | Completed |
| DIVALPROEX 125MG CAP 125MG 68084031301 · Rx 32114 |
— | 28 / 9 days | 1 of 4 | 2023-08-29 | 2023-09-07 | Overdue |
| MULTIVITAMINS MULT VIT 57896050401 · Rx 32117 |
— | 7 / 7 days | 2 of 6 | 2023-08-29 | 2023-09-05 | Overdue |
| FLULAVAL PFS 2023-24 2023-24 19515081452 · Rx 32482 |
— | 0.5 / 1 days | 0 of 0 | 2023-08-18 | 2023-08-19 | Completed |
| ARIPIPRAZOLE 5MG TAB 340B 5MG 13811068030 · Rx 32285 |
— | 30 / 30 days | 3 of 3 | 2023-07-20 | 2023-08-19 | Overdue |
| TRAZODONE 150MG TAB 150MG 50111045002 · Rx 32282 |
— | 30 / 30 days | 3 of 3 | 2023-07-20 | 2023-08-19 | Overdue |
| NIFEDIPINE 10MG CAP 10MG 00228249710 · Rx 32259 |
— | 14 / 14 days | 0 of 0 | 2023-07-26 | 2023-08-09 | Completed |
| AUSTEDO 12MG TAB 12MG 68546017260 · Rx 32335 |
— | 2 / 1 days | 1 of 2 | 2023-08-02 | 2023-08-03 | Overdue |
| LANTUS 100/ML INJ OPTICLIK 00088222052 · Rx 32246 |
— | 15 / 15 days | 0 of 0 | 2023-07-11 | 2023-07-26 | Completed |
| SUBLOCADE 300/1.5 INJ 300/1.5 12496030005 · Rx 32111 |
— | 1.5 / 28 days | 0 of 0 | 2023-05-10 | 2023-06-07 | Completed |
| MODERNA COVID BIVAL BSTR 0.5ML BA4/BA5 80777028299 · Rx 32197 |
— | 0.05 / 1 days | 0 of 0 | 2023-05-31 | 2023-06-01 | Completed |
| SPRAVATO 84MG DOS SOL 84MG DOS 50458002803 · Rx 31822 |
— | 3 / 1 days | 2 of 3 | 2023-04-20 | 2023-04-21 | Overdue |
| NAPROXEN 500MG TAB 500MG 53746019010 · Rx 31886 |
— | 60 / 30 days | 6 of 6 | 2023-03-13 | 2023-04-12 | Overdue |
| ROSUVASTATIN 40MG TAB 40MG 00781540331 · Rx 31863 |
— | 30 / 30 days | 0 of 0 | 2023-03-07 | 2023-04-06 | Completed |
| TOPIRAMATE 100MG TAB 100MG 68382014014 · Rx 31811 |
— | 30 / 30 days | 0 of 0 | 2023-02-01 | 2023-03-03 | Completed |
| CLONIDINE 0.1MG TAB 0.1MG 29300013501 · Rx 31810 |
— | 60 / 30 days | 0 of 0 | 2023-02-01 | 2023-03-03 | Completed |
| LISINOPRIL 10MG TAB 10MG 68180051401 · Rx 31809 |
— | 30 / 30 days | 0 of 0 | 2023-02-01 | 2023-03-03 | Completed |
| LORAZEPAM 2MG TAB 2MG 00228206310 · Rx 31711 |
— | 2 / 1 days | 0 of 0 | 2023-01-06 | 2023-01-07 | Completed |
| ASACOL 400MG EC TAB 400MG DR 00149075215 · Rx 31632 |
— | 30 / 30 days | 3 of 3 | 2022-11-14 | 2022-12-14 | Overdue |
| TRAZODONE 100MG TAB 100MG 00182126089 · Rx 31631 |
— | 30 / 30 days | 3 of 3 | 2022-11-14 | 2022-12-14 | Overdue |
| CALCIUM/D 600/200MG TAB 600MG 60258012106 · Rx 31630 |
— | 60 / 30 days | 3 of 3 | 2022-11-14 | 2022-12-14 | Overdue |
| SPIRONOLACT 50MG TAB 50MG 59762501201 · Rx 31629 |
— | 30 / 30 days | 3 of 3 | 2022-11-14 | 2022-12-14 | Overdue |
| POLYETH GLYC 3350 NF POW 3350 NF 00574041205 · Rx 31628 |
— | 527 / 20 days | 3 of 3 | 2022-11-14 | 2022-12-04 | Overdue |
| TRIAMCINOLON 0.1% CRE 0.1% 00168000415 · Rx 31627 |
— | 15 / 7 days | 3 of 3 | 2022-11-14 | 2022-11-21 | Overdue |