Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| RELAY TEST PLAN | Primary | ||||
| PRIVATE | PR | 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 |
|---|---|---|---|---|---|---|
| ACETAMIN 500MG TAB 500MG 00182845389 · Rx 36269 |
— | 30 / 30 days | 3 of 3 | 2025-12-04 | 2026-01-03 | Overdue |
| COTTON BALLS MIS 87701024760 · Rx 35877 |
— | 7 / 7 days | 3 of 3 | 2025-09-08 | 2025-09-15 | Overdue |
| TRAZODONE 150MG TAB 150MG 60505265501 · Rx 35876 |
— | 7 / 7 days | 3 of 3 | 2025-09-08 | 2025-09-15 | Overdue |
| ALPRAZOLAM 0.25MG TAB 0.25MG 59762371901 · Rx 35875 |
— | 7 / 7 days | 3 of 3 | 2025-09-08 | 2025-09-15 | Overdue |
| XANAX 2MG TAB 2MG 00009009401 · Rx 35649 |
— | 7 / 7 days | 3 of 3 | 2025-07-15 | 2025-07-22 | Overdue |
| DIVALPROEX 125MG DR TAB 125MG DR 00832712215 · Rx 35247 |
— | 30 / 30 days | 3 of 3 | 2025-05-20 | 2025-06-19 | Overdue |
| VIMPAT 50MG TAB 50MG 00131247735 · Rx 35160 |
— | 30 / 30 days | 0 of 1 | 2025-05-20 | 2025-06-19 | Completed |
| ALPRAZOLAM 2MG ER TAB 2MG ER 65162081206 · Rx 35159 |
— | 30 / 30 days | 1 of 2 | 2025-05-20 | 2025-06-19 | Overdue |
| BUSPAR 10MG TAB 10MG 00087081941 · Rx 35248 |
— | 15 / 5 days | 0 of 0 | 2025-05-20 | 2025-05-25 | Completed |
| MAPAP ARTHRITIS 650MG TAB 650MG 00904576960 · Rx 35246 |
— | 10 / 5 days | 3 of 3 | 2025-05-20 | 2025-05-25 | Overdue |
| NAPROXEN 220MG TAB 220MG 00904523059 · Rx 35245 |
— | 10 / 5 days | 3 of 3 | 2025-05-20 | 2025-05-25 | Overdue |
| VYVANSE 30MG CAP 30MG 59417010310 · Rx 35157 |
— | 30 / 30 days | 0 of 0 | 2025-04-17 | 2025-05-17 | Completed |
| APAP/CODEINE 300-30MG TAB 300-30MG 00093015001 · Rx 35158 |
— | 10 / 1 days | 0 of 0 | 2025-04-17 | 2025-04-18 | Completed |
| PSB SYNTHETIC PRODUCT 00093015001 · Rx 35158 |
— | 10 / 1 days | 0 of 0 | 2025-04-17 | 2025-04-18 | Completed |
| NYSTATIN 100000U CRE 100000 00168005430 · Rx 32459 |
— | 30 / 30 days | 1 of 4 | 2024-05-24 | 2024-06-23 | Overdue |
| NAPROXEN 500MG TAB 500MG 53746019001 · Rx 33117 |
— | 10 / 5 days | 0 of 1 | 2024-05-24 | 2024-05-29 | Completed |
| DELSYM 30MG/5ML LIQ 30MG/5ML 53014046343 · Rx 33285 |
— | 89 / 10 days | 0 of 0 | 2024-04-01 | 2024-04-11 | Completed |
| GUAIFENESIN 600MG ER TAB 600MG ER 45802049878 · Rx 33118 |
— | 15 / 5 days | 0 of 1 | 2024-03-07 | 2024-03-12 | Completed |
| AZITHROMYCIN 250MG TAB 250MG 00781149668 · Rx 33116 |
— | 6 / 5 days | 0 of 0 | 2024-02-26 | 2024-03-02 | Completed |
| AUSTEDO 12MG TAB 12MG 68546017260 · Rx 33099 |
— | 2 / 1 days | 10 of 10 | 2024-02-21 | 2024-02-22 | Overdue |
| HYDROCODONE/APAP 10-325MG TAB 10-325MG 53746011001 · Rx 33018 |
— | 10 / 5 days | 0 of 0 | 2024-01-31 | 2024-02-05 | Completed |
| LISINOP-HCTZ 10-12.5 TAB 10-12.5 00185710001 · Rx 32566 |
— | 30 / 30 days | 0 of 0 | 2023-09-25 | 2023-10-25 | Completed |
| SPRAVATO 56MG DOS SOL 56MG DOS 50458002802 · Rx 32688 |
— | 1 / 1 days | 2 of 3 | 2023-10-18 | 2023-10-19 | Overdue |
| SPRAVATO 84MG DOS SOL 84MG DOS 50458002803 · Rx 32689 |
— | 1 / 1 days | 0 of 1 | 2023-10-17 | 2023-10-18 | Completed |
| SKYRIZI 150DOSE INJ 150DOSE 00074204271 · Rx 32635 |
— | 1 / 1 days | 0 of 0 | 2023-10-11 | 2023-10-12 | Completed |
| HYDROCORT 0.5% CRE 0.5% 00168001431 · Rx 32458 |
— | 30 / 30 days | 0 of 0 | 2023-08-10 | 2023-09-09 | Completed |