Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| BRIDGE BRIXADI | Secondary | ||||
| 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 |
|---|---|---|---|---|---|---|
| VYVANSE 10MG CAP 10MG 59417010110 · Rx 36675 |
— | 1 / 1 days | 0 of 0 | 2026-04-14 | 2026-04-15 | Completed |
| APAP/CODEINE 300-30MG TAB 300-30MG 00093015001 · Rx 35671 |
— | 10 / 5 days | 0 of 1 | 2025-11-17 | 2025-11-22 | Completed |
| PSB SYNTHETIC PRODUCT 00093015001 · Rx 35671 |
— | 10 / 5 days | 0 of 1 | 2025-11-17 | 2025-11-22 | Completed |
| VIMPAT 100MG TAB 100MG 00131247835 · Rx 35673 |
— | 15 / 15 days | 0 of 0 | 2025-07-22 | 2025-08-06 | Completed |
| XANAX 0.25MG TAB 0.25MG 00009002901 · Rx 35672 |
— | 10 / 5 days | 0 of 0 | 2025-07-22 | 2025-07-27 | Completed |
| VYVANSE 10MG CAP 10MG 59417010110 · Rx 35670 |
— | 5 / 5 days | 0 of 0 | 2025-07-22 | 2025-07-27 | Completed |
| MODERNA COVID BIVAL BSTR 0.5ML BA4/BA5 80777028299 · Rx 33057 |
— | 0.5 / 1 days | 0 of 0 | 2024-02-09 | 2024-02-10 | Completed |
| BRIXADI MO 128MG/0.36ML INJ 128/0.36 58284022801 · Rx 32723 |
— | 1 / 1 days | 1 of 1 | 2023-10-20 | 2023-10-21 | Overdue |
| ADVAIR HFA 45/21 AER 45/21 00173071520 · Rx 32722 |
— | 12 / 28 days | 3 of 3 | 2023-09-01 | 2023-09-29 | Overdue |