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 |
|---|---|---|---|---|---|---|
| KEPPRA 750MG TAB 750MG 50474059640 · Rx 32414 |
— | 60 / 30 days | 3 of 3 | 2023-08-07 | 2023-09-06 | Overdue |
| DAILY MLTVIT W/IRON TAB W/IRON 63739027401 · Rx 32412 |
— | 30 / 30 days | 3 of 3 | 2023-08-07 | 2023-09-06 | Overdue |
| GALANTAMINE 8MG ER CAP 8MG ER 00378810593 · Rx 32405 |
— | 60 / 30 days | 2 of 2 | 2023-08-07 | 2023-09-06 | Overdue |
| INGREZZA 40MG CAP 40MG 70370204001 · Rx 32404 |
— | 30 / 30 days | 2 of 2 | 2023-08-07 | 2023-09-06 | Overdue |
| TRAZODONE 100MG TAB 100MG 50111043402 · Rx 32419 |
— | 20 / 20 days | 3 of 3 | 2023-08-07 | 2023-08-27 | Overdue |
| ARIPIPRAZOLE 10MG TAB 10MG 65162089809 · Rx 32415 |
— | 10 / 10 days | 2 of 2 | 2023-08-07 | 2023-08-17 | Overdue |
| JELLYBEAN 50505050505 · Rx 32406 |
— | 75 / 8 days | 4 of 4 | 2023-08-07 | 2023-08-15 | Overdue |
| ZALEPLON 10MG CAP 10MG 29300013201 · Rx 32416 |
— | 7 / 7 days | 2 of 2 | 2023-08-07 | 2023-08-14 | Overdue |
| GREEN SKITTLES GREEN8 34387812341 · Rx 32411 |
— | 20 / 4 days | 3 of 3 | 2023-08-07 | 2023-08-11 | Overdue |