Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| PRIVATE | PR | Secondary | |||
| RELAY TEST PLAN COPAY | Secondary | ||||
| RELAY TEST CAPTURED RESP | Secondary | ||||
| RELAY TEST PLAN | 22111 | 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 |
|---|---|---|---|---|---|---|
| TRAZODONE HCL 150MG TAB 150MG 50111045001 · Rx 36099 |
— | 1 / 7 days | 1 of 1 | 2025-11-10 | 2025-11-17 | Overdue |
| COUMADIN 10MG TAB 10MG 00056017475 · Rx 35485 |
— | 7 / 7 days | 1 of 3 | 2025-11-10 | 2025-11-17 | Overdue |
| INGREZZA 60MG CAP 60MG 70370106001 · Rx 35484 |
— | 7 / 7 days | 2 of 3 | 2025-11-05 | 2025-11-12 | Overdue |
| SERTRALINE 100MG TAB-APS 100MG 59762491003 · Rx 36100 |
— | 1 / 1 days | 7 of 7 | 2025-11-10 | 2025-11-11 | Overdue |
| MODERNA COVID BIVAL BSTR 0.5ML BA4/BA5 80777028299 · Rx 36098 |
— | 0.5 / 1 days | 0 of 0 | 2025-11-10 | 2025-11-11 | Completed |
| OLMESARTAN MEDOXOMIL 20MG TAB 20MG 57664075683 · Rx 34467 |
— | 7 / 7 days | 5 of 5 | 2024-12-19 | 2024-12-26 | Overdue |
| LISINOPRIL 5MG TAB 5MG 00185540001 · Rx 32787 |
— | 30 / 30 days | 3 of 5 | 2024-05-30 | 2024-06-29 | Overdue |
| SERTRALINE 100MG TAB 100MG 65862001305 · Rx 33544 |
— | 20 / 20 days | 1 of 2 | 2024-06-06 | 2024-06-26 | Overdue |
| HYDROCHLOROT 12.5MG CAP 12.5MG 00603385521 · Rx 32774 |
— | 28 / 28 days | 2 of 3 | 2024-05-24 | 2024-06-21 | Overdue |
| SUBLOCADE 300/1.5 INJ 300/1.5 12496030001 · Rx 33106 |
— | 1.5 / 28 days | 0 of 0 | 2024-02-22 | 2024-03-21 | Completed |
| MODERNA COVID BIVAL BSTR 0.5ML BA4/BA5 80777028299 · Rx 32848 |
— | 0.5 / 1 days | 0 of 0 | 2023-12-12 | 2023-12-13 | Completed |
| DRONABINOL 5MG CAP 5MG 00591359260 · Rx 32645 |
— | 60 / 30 days | 0 of 0 | 2023-10-11 | 2023-11-10 | Completed |
| SPRAVATO 56MG DOS SOL 56MG DOS 50458002802 · Rx 32698 |
— | 3 / 1 days | 0 of 0 | 2023-10-18 | 2023-10-19 | Completed |
| TRIAMCINOLON 0.1% CREAM 0.1% 51672128202 · Rx 32543 |
— | 30 / 5 days | 0 of 0 | 2023-09-13 | 2023-09-18 | Completed |
| INGREZZA 40-80MG CAP 40-80MG 70370204806 · Rx 32463 |
— | 30 / 30 days | 0 of 0 | 2023-07-30 | 2023-08-29 | Completed |