Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| 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 |
|---|---|---|---|---|---|---|
| DIVALPROEX 250MG DR TAB 250MG DR 57237004701 · Rx 34477 |
— | 90 / 30 days | 1 of 3 | 2025-08-01 | 2025-08-31 | Overdue |
| CALCIUM 600MG TAB 00536342608 · Rx 34476 |
— | 60 / 30 days | 1 of 4 | 2025-08-01 | 2025-08-31 | Overdue |
| LOPRESSOR 50MG TAB 50MG 00028005101 · Rx 35201 |
— | 7 / 7 days | 2 of 3 | 2025-05-27 | 2025-06-03 | Overdue |
| VIMPAT 50MG TAB 50MG 00131247735 · Rx 34475 |
— | 30 / 30 days | 0 of 1 | 2024-12-30 | 2025-01-29 | Completed |
| ALPRAZOLAM 2MG ER TAB 2MG ER 00228308706 · Rx 34474 |
— | 30 / 30 days | 2 of 3 | 2024-12-30 | 2025-01-29 | Overdue |
| VYVANSE 30MG CAP 30MG 59417010310 · Rx 34472 |
— | 30 / 30 days | 0 of 0 | 2024-12-20 | 2025-01-19 | Completed |
| APAP/CODEINE 300-30MG TAB 300-30MG 00093015001 · Rx 34473 |
— | 10 / 1 days | 0 of 0 | 2024-12-20 | 2024-12-21 | Completed |
| PSB SYNTHETIC PRODUCT 00093015001 · Rx 34473 |
— | 10 / 1 days | 0 of 0 | 2024-12-20 | 2024-12-21 | Completed |
| FLUTICASONE 0.005% OIN 0.005% 00168033330 · Rx 34397 |
— | 30 / 30 days | 3 of 3 | 2024-11-20 | 2024-12-20 | Overdue |
| PRADAXA 150MG CAP 150MG 00597013554 · Rx 32792 |
— | 90 / 30 days | 1 of 2 | 2024-11-08 | 2024-12-08 | Overdue |
| NAPROXEN SOD 220MG TAB 220MG 00182109719 · Rx 32160 |
— | 30 / 10 days | 2 of 3 | 2023-11-16 | 2023-11-26 | Overdue |
| ENBREL 25MG INJ 25MG 58406042534 · Rx 32629 |
— | 4 / 4 days | 0 of 0 | 2023-10-10 | 2023-10-14 | Completed |
| AUSTEDO 6MG TAB 6MG 68546017060 · Rx 32312 |
— | 1 / 1 days | 1 of 2 | 2023-10-11 | 2023-10-12 | Overdue |
| FLUOXETINE 40MG CAP 40MG 00781282401 · Rx 32090 |
— | 90 / 30 days | 1 of 3 | 2023-08-01 | 2023-08-31 | Overdue |
| IBUPROFEN 400MG TAB 400MG 49884077701 · Rx 32381 |
— | 14 / 14 days | 4 of 5 | 2023-08-02 | 2023-08-16 | Overdue |
| SUBLOCADE 100/0.5 INJ 100/0.5 12496010001 · Rx 32109 |
— | 0.5 / 28 days | 0 of 0 | 2023-05-10 | 2023-06-07 | Completed |
| VITAMIN A&D OIN 00085009604 · Rx 31981 |
— | 454 / 30 days | 0 of 0 | 2023-04-11 | 2023-05-11 | Completed |
| OZEMPIC 2/1.5ML INJ 2/1.5ML 00169413602 · Rx 31852 |
— | 1.5 / 28 days | 0 of 0 | 2023-02-28 | 2023-03-28 | Completed |
| SPRAVATO 56MG DOS SOL 56MG DOS 50458002802 · Rx 31838 |
— | 1 / 1 days | 4 of 5 | 2023-03-24 | 2023-03-25 | Overdue |