Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| RELAY TEST PLAN | Primary | ||||
| 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 |
|---|---|---|---|---|---|---|
| NAPROXEN 500MG TAB 500MG 00093014905 · Rx 37015 |
— | 10 / 10 days | 2 of 2 | 2026-07-02 | 2026-07-12 | Overdue |
| FANAPT 8MG TAB 8MG 43068010802 · Rx 36915 |
— | 60 / 30 days | 2 of 2 | 2026-06-04 | 2026-07-04 | Overdue |
| DIAZEPAM 10MG GEL 10MG 00093613832 · Rx 36741 |
— | 1 / 1 days | 0 of 0 | 2026-05-01 | 2026-05-02 | Completed |
| VYVANSE 30MG CAP 30MG 59417010310 · Rx 35666 |
— | 30 / 30 days | 0 of 0 | 2025-07-22 | 2025-08-21 | Completed |
| VIMPAT 100MG TAB 100MG 00131247835 · Rx 35669 |
— | 15 / 15 days | 0 of 0 | 2025-07-22 | 2025-08-06 | Completed |
| VALIUM 10MG TAB 10MG 54868098701 · Rx 35668 |
— | 3 / 3 days | 0 of 0 | 2025-07-22 | 2025-07-25 | Completed |
| APAP/CODEINE 300-30MG TAB 300-30MG 00093015001 · Rx 35667 |
— | 10 / 1 days | 0 of 0 | 2025-07-22 | 2025-07-23 | Completed |
| PSB SYNTHETIC PRODUCT 00093015001 · Rx 35667 |
— | 10 / 1 days | 0 of 0 | 2025-07-22 | 2025-07-23 | Completed |
| GUAIFENESIN 100/5ML SOL 100/5ML 00121074408 · Rx 32615 |
— | 237 / 5 days | 0 of 0 | 2024-03-20 | 2024-03-25 | Completed |
| ROPINIROLE 0.5MG TAB 0.5MG 64720020210 · Rx 32877 |
— | 56 / 28 days | 3 of 3 | 2023-12-19 | 2024-01-16 | Overdue |
| GUANFACINE 1MG **ER** TAB 1MG ER 00781545101 · Rx 32870 |
— | 30 / 30 days | 3 of 3 | 2023-12-13 | 2024-01-12 | Overdue |
| WELLBUTRIN XL 150MG TAB XL 150MG 00187073030 · Rx 32862 |
— | 30 / 30 days | 3 of 3 | 2023-12-13 | 2024-01-12 | Overdue |
| TYLENOL ARTH 650MG TAB 650MG 50580011225 · Rx 32871 |
— | 28 / 28 days | 1 of 1 | 2023-12-13 | 2024-01-10 | Overdue |
| LITHIUM CARB 150MG CAP 150MG 00054252625 · Rx 32869 |
— | 84 / 28 days | 3 of 3 | 2023-12-13 | 2024-01-10 | Overdue |
| LISINOP-HCTZ 20-12.5 TAB 20-12.5 00172503460 · Rx 32868 |
— | 14 / 28 days | 3 of 3 | 2023-12-13 | 2024-01-10 | Overdue |
| IDP-LEVOTHYROXINE 100MCG TAB 100MCG 00378180901 · Rx 32867 |
— | 28 / 28 days | 3 of 3 | 2023-12-13 | 2024-01-10 | Overdue |
| 49230064021 49230064021 · Rx 32865 |
— | 56 / 28 days | 3 of 3 | 2023-12-13 | 2024-01-10 | Overdue |
| BUSPIRONE 15MG TAB 15MG 00378116580 · Rx 32864 |
— | 84 / 28 days | 3 of 3 | 2023-12-13 | 2024-01-10 | Overdue |
| DIVALPROEX 250MG DR TAB 250MG DR 00832712315 · Rx 32863 |
— | 112 / 28 days | 3 of 3 | 2023-12-13 | 2024-01-10 | Overdue |
| ATOMOXETINE HCL 10MG CAP 10MG 68462026530 · Rx 32861 |
— | 28 / 28 days | 3 of 3 | 2023-12-13 | 2024-01-10 | Overdue |
| ARIPIPRAZOLE 20MG TAB 20MG 65162090103 · Rx 32860 |
— | 28 / 28 days | 3 of 3 | 2023-12-13 | 2024-01-10 | Overdue |
| ATORVASTATIN 20MG TAB 20MG 60505257908 · Rx 32859 |
— | 28 / 28 days | 3 of 3 | 2023-12-13 | 2024-01-10 | Overdue |
| LITHIUM CARB 600MG CAP 600MG 00054253125 · Rx 32579 |
— | 56 / 28 days | 3 of 3 | 2023-09-27 | 2023-10-25 | Overdue |
| DULOXETINE 20MG CAP 20MG 66993007560 · Rx 32682 |
— | 5 / 5 days | 6 of 6 | 2023-10-16 | 2023-10-21 | Overdue |
| PSEUDOEPHEDR 120MG CR CAP 120MG ER 37205044652 · Rx 32614 |
— | 24 / 12 days | 3 of 3 | 2023-10-06 | 2023-10-18 | Overdue |
| SKYRIZI 150DOSE INJ 150DOSE 00074204271 · Rx 32664 |
— | 1 / 5 days | 3 of 3 | 2023-10-11 | 2023-10-16 | Overdue |
| ENBREL 25MG INJ 25MG 58406042534 · Rx 32628 |
— | 4 / 4 days | 0 of 0 | 2023-10-10 | 2023-10-14 | Completed |
| AUSTEDO 9MG TAB 9MG 68546017160 · Rx 32310 |
— | 1 / 1 days | 1 of 3 | 2023-10-11 | 2023-10-12 | Overdue |
| MODERNA COVID BIVAL BSTR 0.5ML BA4/BA5 80777028299 · Rx 32607 |
— | 0.5 / 1 days | 0 of 0 | 2023-10-05 | 2023-10-06 | Completed |
| AFLURIA QUAD SY 10X0.5ML 17-18 PF 17-18 33332031701 · Rx 32580 |
— | 0.5 / 1 days | 0 of 0 | 2023-09-27 | 2023-09-28 | Completed |
| ENGERIX-B 10/0.5ML INJ 10/0.5ML 58160082011 · Rx 32392 |
— | 0.5 / 1 days | 0 of 0 | 2023-08-03 | 2023-08-04 | Completed |
| MODERNA COVID BIVAL BSTR 0.5ML BA4/BA5 80777028299 · Rx 32391 |
— | 0.5 / 1 days | 0 of 0 | 2023-08-03 | 2023-08-04 | Completed |
| PFIZER COVID BIVAL BSTR BA4/BA5 59267030402 · Rx 32390 |
— | 0.3 / 1 days | 0 of 0 | 2023-08-03 | 2023-08-04 | Completed |
| ENGERIX-B 10/0.5ML INJ 10/0.5ML 58160082011 · Rx 32190 |
— | 0.5 / 1 days | 0 of 0 | 2023-05-31 | 2023-06-01 | Completed |
| MODERNA COVID BIVAL BSTR 0.5ML BA4/BA5 80777028299 · Rx 32183 |
— | 0.05 / 1 days | 0 of 0 | 2023-05-31 | 2023-06-01 | Completed |
| PFIZER COVID BIVAL BSTR BA4/BA5 59267030402 · Rx 32182 |
— | 0.3 / 1 days | 0 of 0 | 2023-05-31 | 2023-06-01 | Completed |