Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| 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 |
|---|---|---|---|---|---|---|
| DIVALPROEX ER 500MG TAB 500MG ER 10370051110 · Rx 36914 |
— | 90 / 30 days | 99 of 99 | 2026-06-03 | 2026-07-03 | Overdue |
| DIVALPROEX 125MG CAP 125MG 68084031301 · Rx 36913 |
— | 90 / 30 days | 99 of 99 | 2026-06-03 | 2026-07-03 | Overdue |
| VITAMIN C 1000MG TAB 1000MG 00904501360 · Rx 36912 |
— | 60 / 30 days | 99 of 99 | 2026-06-03 | 2026-07-03 | Overdue |
| MELATONIN 5MG CAP 5MG 74312015745 · Rx 36909 |
— | 30 / 30 days | 99 of 99 | 2026-06-03 | 2026-07-03 | Overdue |
| BUSPIRONE 10MG TAB 10MG 64380074208 · Rx 36904 |
— | 90 / 30 days | 99 of 99 | 2026-06-03 | 2026-07-03 | Overdue |
| HYDROXYZINE PAM 25MG CAP 25MG 00185067401 · Rx 36903 |
— | 120 / 30 days | 99 of 99 | 2026-06-03 | 2026-07-03 | Overdue |
| VITAMIN D 1000 UNIT TAB 1000UNIT 00536333401 · Rx 36911 |
— | 28 / 28 days | 99 of 99 | 2026-06-03 | 2026-07-01 | Overdue |
| GUANFACINE 1MG **ER** TAB 1MG ER 00781545101 · Rx 36910 |
— | 28 / 28 days | 99 of 99 | 2026-06-03 | 2026-07-01 | Overdue |
| DIPHENHYDRAM 50MG CAP 50MG 00555005905 · Rx 36908 |
— | 28 / 28 days | 99 of 99 | 2026-06-03 | 2026-07-01 | Overdue |
| OLANZAPINE 15MG TAB 15MG 00093577101 · Rx 36907 |
— | 28 / 28 days | 99 of 99 | 2026-06-03 | 2026-07-01 | Overdue |
| PAP-ABILIFY 15MG TAB 15MG 59148000913 · Rx 36906 |
— | 28 / 28 days | 99 of 99 | 2026-06-03 | 2026-07-01 | Overdue |
| FLUOXETINE 20MG CAP 20MG 65862019399 · Rx 36905 |
— | 28 / 28 days | 99 of 99 | 2026-06-03 | 2026-07-01 | Overdue |
| TRAZODONE 150MG TAB 150MG 00591230001 · Rx 36902 |
— | 28 / 28 days | 99 of 99 | 2026-06-03 | 2026-07-01 | Overdue |
| CALCIUM + D 600MG TAB 600MG 00904585652 · Rx 36901 |
— | 28 / 28 days | 99 of 99 | 2026-06-03 | 2026-07-01 | Overdue |
| TORSEMIDE 10MG TAB 10MG 31722053001 · Rx 36900 |
— | 28 / 28 days | 99 of 99 | 2026-06-03 | 2026-07-01 | Overdue |
| MULTIVITAMIN TAB 00536404610 · Rx 36899 |
— | 28 / 28 days | 99 of 99 | 2026-06-03 | 2026-07-01 | Overdue |
| BUSPIRONE 10MG TAB 10MG 00093005401 · Rx 36865 |
— | 56 / 28 days | 2 of 2 | 2026-05-29 | 2026-06-26 | Overdue |
| SODIUM BICAR 650MG TAB 650MG 00677013110 · Rx 36560 |
— | 14 / 14 days | 10 of 10 | 2026-03-13 | 2026-03-27 | Overdue |
| ASPIRIN 81MG EC TAB 81MG EC 00536100441 · Rx 36562 |
— | 7 / 7 days | 7 of 7 | 2026-03-13 | 2026-03-20 | Overdue |
| PHOSLO 667MG TAB 667MG 59730640101 · Rx 36561 |
— | 7 / 7 days | 7 of 7 | 2026-03-13 | 2026-03-20 | Overdue |
| PSEUDOEPHEDR 120MG CR CAP 120MG ER 37205044652 · Rx 36559 |
— | 7 / 7 days | 3 of 3 | 2026-03-13 | 2026-03-20 | Overdue |
| CHANTIX 1MG PAK 1MG 00069046912 · Rx 36558 |
— | 7 / 7 days | 3 of 3 | 2026-03-13 | 2026-03-20 | Overdue |
| LITHIUM CARB 300MG CAP 300MG 00054252731 · Rx 36557 |
— | 14 / 7 days | 10 of 10 | 2026-03-13 | 2026-03-20 | Overdue |
| LITHIUM CARB 150MG CAP 150MG 31722054401 · Rx 36556 |
— | 21 / 7 days | 7 of 7 | 2026-03-13 | 2026-03-20 | Overdue |
| NICOTINE POL 2MG MINT LOZ 2MG MINT 00113034405 · Rx 36555 |
— | 14 / 7 days | 10 of 10 | 2026-03-13 | 2026-03-20 | Overdue |
| NICOTINE 4MG GUM 4MG 37205020471 · Rx 36554 |
— | 28 / 7 days | 10 of 10 | 2026-03-13 | 2026-03-20 | Overdue |
| FLINTSTONES TODDLER CHW TODDLER 16500055389 · Rx 36553 |
— | 14 / 7 days | 10 of 10 | 2026-03-13 | 2026-03-20 | Overdue |
| ROSUVASTATIN 10MG TAB 10MG 31722088390 · Rx 36552 |
— | 7 / 7 days | 3 of 3 | 2026-03-13 | 2026-03-20 | Overdue |
| GUAIFENESIN 200MG TAB 200MG 00904515460 · Rx 36551 |
— | 14 / 7 days | 10 of 10 | 2026-03-13 | 2026-03-20 | Overdue |
| BENADRYL CHILD ALLERGY 12.5MG 12.5MG 50580023201 · Rx 36550 |
— | 7 / 7 days | 10 of 10 | 2026-03-13 | 2026-03-20 | Overdue |
| TRAZODONE 150MG TAB 150MG 60505265501 · Rx 36549 |
— | 7 / 7 days | 10 of 10 | 2026-03-13 | 2026-03-20 | Overdue |
| DIVALPROEX 125MG CAP 125MG 00378800801 · Rx 36548 |
— | 7 / 7 days | 10 of 10 | 2026-03-13 | 2026-03-20 | Overdue |
| DIVALPROEX 250MG DR TAB 250MG DR 68382003205 · Rx 36547 |
— | 7 / 7 days | 10 of 10 | 2026-03-13 | 2026-03-20 | Overdue |
| CALTRATE 600 +D TAB 600-800 00005550925 · Rx 36546 |
— | 7 / 7 days | 10 of 10 | 2026-03-13 | 2026-03-20 | Overdue |
| GAVISCON 80-20MG TAB 00088117547 · Rx 36545 |
— | 7 / 7 days | 10 of 10 | 2026-03-13 | 2026-03-20 | Overdue |
| DIPHEN/ATROP 2.5MG TAB 2.5MG 00378041501 · Rx 36544 |
— | 7 / 7 days | 3 of 3 | 2026-03-13 | 2026-03-20 | Overdue |
| NORVASC 2.5MG TAB 2.5MG 00069152068 · Rx 36543 |
— | 7 / 7 days | 7 of 7 | 2026-03-13 | 2026-03-20 | Overdue |
| L-LYSINE 500MG TAB 500MG 43292050012 · Rx 36542 |
— | 7 / 7 days | 10 of 10 | 2026-03-13 | 2026-03-20 | Overdue |
| LEVOTHYROXIN 75MCG TAB 75MCG 00378180501 · Rx 36541 |
— | 7 / 7 days | 10 of 10 | 2026-03-13 | 2026-03-20 | Overdue |
| VITAMIN C 1000MG TAB 1000MG 00182152801 · Rx 36540 |
— | 7 / 7 days | 10 of 10 | 2026-03-13 | 2026-03-20 | Overdue |
| VESICARE 10MG TAB 10MG 51248015101 · Rx 36539 |
— | 7 / 7 days | 10 of 10 | 2026-03-13 | 2026-03-20 | Overdue |
| ONDANSETRON 4MG TAB 4MG 00093023356 · Rx 36538 |
— | 7 / 7 days | 10 of 10 | 2026-03-13 | 2026-03-20 | Overdue |
| BUSPIRONE 10MG TAB 10MG 00378115001 · Rx 36468 |
— | 84 / 28 days | 10 of 10 | 2026-02-12 | 2026-03-12 | Overdue |
| MULTIVIT/FL 1MG CHW 1MG 59088010959 · Rx 36473 |
— | 14 / 7 days | 10 of 10 | 2026-02-27 | 2026-03-06 | Overdue |
| TRIAMT/HCTZ 75-50MG TAB 75-50MG 60505265701 · Rx 34815 |
— | 28 / 28 days | 1 of 3 | 2026-02-01 | 2026-03-01 | Overdue |
| VITAMIN E 1000IU CAP 1000UNIT 00904027760 · Rx 34814 |
— | 28 / 28 days | 1 of 3 | 2026-02-01 | 2026-03-01 | Overdue |
| CALCIUM + D 600MG TAB 600MG 00904585652 · Rx 34813 |
— | 28 / 28 days | 1 of 3 | 2026-02-01 | 2026-03-01 | Overdue |
| MULTIVITAMIN/ FE /IRON 74312001580 · Rx 34812 |
— | 28 / 28 days | 1 of 3 | 2026-02-01 | 2026-03-01 | Overdue |
| ONDANSETRON 4MG ODT TAB 4MG ODT 68462015713 · Rx 34810 |
— | 56 / 28 days | 1 of 3 | 2026-02-01 | 2026-03-01 | Overdue |
| BENZTROPINE 2MG TAB 2MG 00603243932 · Rx 34809 |
— | 28 / 28 days | 1 of 3 | 2026-02-01 | 2026-03-01 | Overdue |
| HALOPERIDOL 5MG TAB 5MG 00781139601 · Rx 34808 |
— | 56 / 28 days | 1 of 3 | 2026-02-01 | 2026-03-01 | Overdue |
| JARDIANCE 10MG TAB 10MG 00597015230 · Rx 34807 |
— | 28 / 28 days | 1 of 3 | 2026-02-01 | 2026-03-01 | Overdue |
| POT CL MICRO 20MEQ ER TAB 20MEQ ER 00832532511 · Rx 34806 |
— | 28 / 28 days | 1 of 3 | 2026-02-01 | 2026-03-01 | Overdue |
| CLOPIDOGREL 75MG TAB 75MG 00378362777 · Rx 34805 |
— | 28 / 28 days | 1 of 3 | 2026-02-01 | 2026-03-01 | Overdue |
| ALLOPURINOL 100MG TAB 100MG 00603211521 · Rx 34804 |
— | 28 / 28 days | 1 of 3 | 2026-02-01 | 2026-03-01 | Overdue |
| METHYLPRED 4MG TAB 4MG 68382091601 · Rx 34803 |
— | 28 / 28 days | 1 of 3 | 2026-02-01 | 2026-03-01 | Overdue |
| ESCITALOPRAM 20MG TAB 20MG 00378385777 · Rx 34802 |
— | 28 / 28 days | 1 of 3 | 2026-02-01 | 2026-03-01 | Overdue |
| PRAZOSIN HCL 2MG CAP 2MG 00378230201 · Rx 34801 |
may take up to 1 hr before bedtime adding in more words to test total | 28 / 28 days | 1 of 3 | 2026-02-01 | 2026-03-01 | Overdue |
| MELATONIN QD 10MG TAB 10MG 00536139708 · Rx 34800 |
— | 28 / 28 days | 1 of 3 | 2026-02-01 | 2026-03-01 | Overdue |
| OLANZAPINE 5MG TAB 5MG 66993004830 · Rx 34799 |
— | 28 / 28 days | 1 of 3 | 2026-02-01 | 2026-03-01 | Overdue |
| METOPROLOL SUCC 100MG ER TAB 100MG ER 62037083201 · Rx 34798 |
— | 28 / 28 days | 1 of 3 | 2026-02-01 | 2026-03-01 | Overdue |
| LOSARTAN POT 100MG TAB 100MG 58657061230 · Rx 34797 |
— | 28 / 28 days | 1 of 3 | 2026-02-01 | 2026-03-01 | Overdue |
| PROTONIX 40MG TAB 40MG 00008084181 · Rx 34796 |
— | 28 / 28 days | 1 of 3 | 2026-02-01 | 2026-03-01 | Overdue |
| AMLODIPINE 10MG TAB 10MG 69097083815 · Rx 34795 |
— | 28 / 28 days | 1 of 3 | 2026-02-01 | 2026-03-01 | Overdue |
| EZETIMIBE 10MG TAB 10MG 51660020030 · Rx 34794 |
— | 28 / 28 days | 1 of 3 | 2026-02-01 | 2026-03-01 | Overdue |
| TORSEMIDE 20MG TAB 20MG 31722053101 · Rx 34793 |
— | 28 / 28 days | 1 of 3 | 2026-02-01 | 2026-03-01 | Overdue |
| ESCITALOPRAM 10MG TAB 10MG 00378385677 · Rx 36467 |
— | 7 / 7 days | 10 of 10 | 2026-02-12 | 2026-02-19 | Overdue |
| XARELTO 20MG TAB 20MG 50458057930 · Rx 36466 |
— | 7 / 7 days | 10 of 10 | 2026-02-12 | 2026-02-19 | Overdue |
| MI-ACID SUS 00904000414 · Rx 35171 |
— | 30 / 30 days | 4 of 5 | 2025-08-01 | 2025-08-31 | Overdue |
| DIVALPROEX EC 500MG TAB 500MG DR 62756079888 · Rx 35130 |
— | 112 / 28 days | 2 of 3 | 2025-08-01 | 2025-08-29 | Overdue |
| HALOPER DEC 50MG/ML INJ 50MG/ML 00144044451 · Rx 35172 |
Adding comments to use all available space in expanded directions on l | 30 / 30 days | 5 of 5 | 2025-04-24 | 2025-05-24 | Overdue |
| AMOXICILLIN 500MG CAP 500MG 63304065501 · Rx 34811 |
— | 56 / 28 days | 3 of 3 | 2025-02-10 | 2025-03-10 | Overdue |
| QUETIAPINE 200MG TAB 200MG 67877024601 · Rx 32572 |
— | 20 / 10 days | 0 of 1 | 2024-08-23 | 2024-09-02 | Completed |
| ZYPREXA RELP 405MG INJ 405MG 00002763711 · Rx 33699 |
— | 1 / 28 days | 10 of 10 | 2024-07-23 | 2024-08-20 | Overdue |
| LANCETS MIS 38415010028 · Rx 33352 |
— | 100 / 1 days | 5 of 5 | 2024-04-23 | 2024-04-24 | Overdue |
| CLOPIDOGREL 75MG TAB 75MG 16729021810 · Rx 33213 |
— | 30 / 30 days | 3 of 3 | 2024-03-12 | 2024-04-11 | Overdue |
| SPRAVATO 56MG DOS SOL 56MG DOS 50458002802 · Rx 32709 |
— | 1 / 1 days | 2 of 3 | 2024-01-17 | 2024-01-18 | Overdue |
| NAPROXEN 220MG TAB 220MG 00904523059 · Rx 32801 |
test | 30 / 10 days | 3 of 3 | 2023-12-01 | 2023-12-11 | Overdue |
| IBUPROFEN 100/5ML SUS 100/5ML 45802095243 · Rx 32423 |
— | 120 / 14 days | 3 of 5 | 2023-10-19 | 2023-11-02 | Overdue |
| MAPAP 160/5ML ELX 160/5ML 00904198520 · Rx 32379 |
— | 120 / 14 days | 4 of 5 | 2023-10-19 | 2023-11-02 | Overdue |
| CLOPIDOGREL 75MG TAB 75MG 16729021810 · Rx 32153 |
— | 30 / 30 days | 3 of 4 | 2023-09-21 | 2023-10-21 | Overdue |
| CLOZAPINE 100/ODT TAB 100/ODT 00093301084 · Rx 32571 |
— | 30 / 15 days | 1 of 1 | 2023-09-25 | 2023-10-10 | Overdue |
| IBUPROFEN 400MG 400MG 67877029401 · Rx 32570 |
— | 20 / 10 days | 2 of 2 | 2023-09-25 | 2023-10-05 | Overdue |
| SAMBUCOL BLACK ELDERBERRY LOZ 50-3MG 96116000120 · Rx 32569 |
— | 20 / 7 days | 2 of 2 | 2023-09-25 | 2023-10-02 | Overdue |
| QUININE SULF 200MG CAP 200MG 00172417160 · Rx 32560 |
— | 20 / 10 days | 4 of 4 | 2023-09-20 | 2023-09-30 | Overdue |
| MAGNESIUM OXIDE 400MG TAB 400MG 60258017101 · Rx 32559 |
— | 20 / 10 days | 2 of 2 | 2023-09-20 | 2023-09-30 | Overdue |
| PROGESTERONE 100MG CAP 100MG 17478076610 · Rx 32434 |
— | 30 / 30 days | 1 of 1 | 2023-07-28 | 2023-08-27 | Overdue |
| DAILY MULTI TAB 30768000747 · Rx 32132 |
— | 20 / 20 days | 1 of 1 | 2023-08-01 | 2023-08-21 | Overdue |
| AUSTEDO 12MG TAB 12MG 68546017260 · Rx 32308 |
— | 1 / 1 days | 3 of 3 | 2023-07-26 | 2023-07-27 | Overdue |
| DAILY MULTI TAB 30768000747 · Rx 32131 |
— | 30 / 30 days | 3 of 3 | 2023-05-16 | 2023-06-15 | Overdue |
| ENGERIX-B 10/0.5ML INJ 10/0.5ML 58160082011 · Rx 32196 |
— | 1 / 1 days | 0 of 0 | 2023-05-31 | 2023-06-01 | Completed |
| GARDASIL INJ 00006404541 · Rx 32192 |
— | 1 / 1 days | 0 of 0 | 2023-05-31 | 2023-06-01 | Completed |