Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| RELAY TEST PLAN | Primary | ||||
| CHANGE HEALTHCARE | 123 | Secondary | |||
| PRIVATE | PR | Secondary | |||
| YESSICA'S TEST OPEN ITEM | 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 |
|---|---|---|---|---|---|---|
| CITALOPRAM 10MG TAB 10MG 00378623105 · Rx 36448 |
— | 30 / 30 days | 12 of 12 | 2026-01-30 | 2026-03-01 | Overdue |
| SERTRALINE 100MG TAB 100MG 16714061305 · Rx 36447 |
— | 30 / 30 days | 12 of 12 | 2026-01-30 | 2026-03-01 | Overdue |
| DIVALPROEX 250MG DR TAB 250MG DR 57237004701 · Rx 35860 |
— | 90 / 30 days | 1 of 3 | 2025-12-11 | 2026-01-10 | Overdue |
| TRAZODONE 300MG TAB 300MG 00555073302 · Rx 36351 |
— | 1 / 1 days | 99 of 99 | 2025-12-24 | 2025-12-25 | Overdue |
| CETIRIZINE HCL 10MG 10MG 00378363701 · Rx 36350 |
— | 1 / 1 days | 99 of 99 | 2025-12-24 | 2025-12-25 | Overdue |
| XYZAL 5MG TAB 5MG 00024580090 · Rx 36349 |
— | 1 / 1 days | 99 of 99 | 2025-12-24 | 2025-12-25 | Overdue |
| VERAPAMIL 100MG ER CAP-APS 100MG ER 00378620101 · Rx 36348 |
— | 1 / 1 days | 99 of 99 | 2025-12-24 | 2025-12-25 | Overdue |
| CALCIUM + D 600MG TAB 600MG 00904585652 · Rx 36347 |
— | 1 / 1 days | 99 of 99 | 2025-12-24 | 2025-12-25 | Overdue |
| CALCIUM 600MG TAB 600MG 37864073099 · Rx 35859 |
— | 60 / 30 days | 2 of 3 | 2025-11-17 | 2025-12-17 | Overdue |
| VIMPAT 50MG TAB 50MG 00131247735 · Rx 35858 |
— | 30 / 30 days | 0 of 1 | 2025-11-17 | 2025-12-17 | Completed |
| ALPRAZOLAM 2MG ER TAB 2MG ER 65162081206 · Rx 35857 |
— | 30 / 30 days | 2 of 2 | 2025-09-02 | 2025-10-02 | Overdue |
| VYVANSE 30MG CAP 30MG 59417010310 · Rx 35855 |
— | 30 / 30 days | 0 of 0 | 2025-09-02 | 2025-10-02 | Completed |
| APAP/CODEINE 300-30MG TAB 300-30MG 00093015001 · Rx 35856 |
— | 10 / 1 days | 0 of 0 | 2025-09-02 | 2025-09-03 | Completed |
| PSB SYNTHETIC PRODUCT 00093015001 · Rx 35856 |
— | 10 / 1 days | 0 of 0 | 2025-09-02 | 2025-09-03 | Completed |
| SPRAVATO 84MG DOS SOL 84MG DOS 50458002803 · Rx 32914 |
— | 20 / 7 days | 2 of 2 | 2024-04-29 | 2024-05-06 | Overdue |
| SPRAVATO 56MG DOS SOL 56MG DOS 50458002802 · Rx 32913 |
— | 20 / 10 days | 2 of 2 | 2024-01-10 | 2024-01-20 | Overdue |
| SKYRIZI 150DOSE INJ 150DOSE 00074204271 · Rx 32636 |
— | 1 / 30 days | 0 of 0 | 2023-10-11 | 2023-11-10 | Completed |
| NOVOLOG 70/30 FLEXPEN INJ FLEXPEN 00169369619 · Rx 32549 |
— | 15 / 31 days | 0 of 0 | 2023-09-13 | 2023-10-14 | Completed |
| NOVOFINE 30 DISPOS MIS 30GX8MM 00169185275 · Rx 32548 |
— | 100 / 30 days | 0 of 0 | 2023-09-13 | 2023-10-13 | Completed |
| SHINGRIX 50/0.5ML INJ 50/0.5ML 58160082311 · Rx 32396 |
— | 1 / 1 days | 0 of 0 | 2023-08-03 | 2023-08-04 | Completed |
| PFIZER COVID BIVAL BSTR BA4/BA5 59267030402 · Rx 32395 |
— | 0.3 / 1 days | 0 of 0 | 2023-08-03 | 2023-08-04 | Completed |
| INGREZZA 80MG CAP 80MG 70370108001 · Rx 32311 |
— | 1 / 1 days | 3 of 3 | 2023-07-27 | 2023-07-28 | Overdue |
| MEDIHOL BASE GEL 38779225809 · Rx 32158 |
— | 1000 / 30 days | 0 of 0 | 2023-05-24 | 2023-06-23 | Completed |