Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| RELAY TEST PLAN | Primary | ||||
| ADDERAL | Secondary | ||||
| PRIVATE | PR | Secondary | |||
| RELAY TEST PLAN COPAY | 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 |
|---|---|---|---|---|---|---|
| ADVIL 200MG TAB 200MG 00573015046 · Rx 33179 |
— | 100 / 100 days | 0 of 0 | 2024-03-07 | 2024-06-15 | Completed |
| SKYRIZI 150DOSE INJ 150DOSE 00074204271 · Rx 32641 |
— | 1 / 28 days | 0 of 0 | 2023-10-11 | 2023-11-08 | Completed |
| RISPERDAL CONSTA 12.5MG INJ 12.5MG 50458030911 · Rx 32582 |
— | 2 / 28 days | 0 of 0 | 2023-09-27 | 2023-10-25 | Completed |
| SPRAVATO 56MG DOS SOL 56MG DOS 50458002802 · Rx 32701 |
— | 3 / 1 days | 3 of 3 | 2023-10-18 | 2023-10-19 | Overdue |
| ALCOHOL PADS 00000001104 · Rx 32547 |
— | 100 / 30 days | 5 of 5 | 2023-09-13 | 2023-10-13 | Overdue |
| FLUTICASONE 50MCG SPR 50MCG 60505082901 · Rx 32546 |
— | 16 / 30 days | 5 of 5 | 2023-09-13 | 2023-10-13 | Overdue |
| HYDROCORTISONE 2.5% CREAM 2.5% 00168008031 · Rx 32542 |
— | 30 / 30 days | 0 of 0 | 2023-09-13 | 2023-10-13 | Completed |
| ENBREL 25MG INJ 25MG 58406042534 · Rx 32640 |
— | 1 / 1 days | 0 of 0 | 2023-10-11 | 2023-10-12 | Completed |
| ARIPIPRAZOLE 20MG TAB 20MG 65162090103 · Rx 32136 |
— | 20 / 20 days | 3 of 3 | 2023-08-01 | 2023-08-21 | Overdue |
| FLULAVAL QUA 2023-24 INJ 2023-24 19515081441 · Rx 32483 |
— | 0.5 / 1 days | 0 of 0 | 2023-08-18 | 2023-08-19 | Completed |
| NAPROXEN 500MG TAB 500MG 67253062250 · Rx 32427 |
— | 28 / 14 days | 0 of 0 | 2023-08-02 | 2023-08-16 | Completed |
| INGREZZA 60MG CAP 60MG 70370106001 · Rx 32324 |
— | 1 / 1 days | 1 of 1 | 2023-07-27 | 2023-07-28 | Overdue |