Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| PRIVATE | PR | Secondary | |||
| RELAY TEST PLAN COPAY | 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 |
|---|---|---|---|---|---|---|
| NAPROXEN 220MG TAB 220MG 00904523059 · Rx 36352 |
— | 1 / 1 days | 98 of 99 | 2026-02-13 | 2026-02-14 | Overdue |
| WEGOVY 0.25MG INJ 0.25MG 00169452514 · Rx 36389 |
— | 2 / 2 days | 1 of 1 | 2026-01-05 | 2026-01-07 | Overdue |
| BUPROPION XL 300MG TAB 300MG XL 00591333230 · Rx 36353 |
— | 99 / 1 days | 98 of 99 | 2025-12-24 | 2025-12-25 | Overdue |
| TYLENOL/COD #3 TAB #3 50458051360 · Rx 35680 |
— | 10 / 10 days | 1 of 1 | 2025-07-23 | 2025-08-02 | Overdue |
| VIMPAT 50MG TAB 50MG 00131247735 · Rx 35682 |
— | 5 / 5 days | 0 of 0 | 2025-07-23 | 2025-07-28 | Completed |
| VALIUM 2MG TAB 2MG 00140000401 · Rx 35681 |
— | 10 / 5 days | 0 of 0 | 2025-07-23 | 2025-07-28 | Completed |
| HYDROCODONE/APAP 5-325MG TAB 5-325MG 53746010901 · Rx 35679 |
— | 10 / 5 days | 0 of 0 | 2025-07-23 | 2025-07-28 | Completed |
| BENZTROPINE 0.5MG TAB 0.5MG 76385010301 · Rx 34675 |
— | 30 / 30 days | 3 of 3 | 2025-01-29 | 2025-02-28 | Overdue |
| BUPROPION XL 300MG TAB 300MG XL 10370010250 · Rx 34674 |
— | 7 / 7 days | 3 of 3 | 2025-01-29 | 2025-02-05 | Overdue |
| TRAZODONE 100 MG TAB- SAMPLE 100MG 53489051101 · Rx 32832 |
— | 30 / 30 days | 1 of 2 | 2024-11-08 | 2024-12-08 | Overdue |
| MAPAP ARTHRITIS 650MG TAB 650MG 00904576960 · Rx 32827 |
— | 28 / 28 days | 3 of 3 | 2023-12-06 | 2024-01-03 | Overdue |
| NAPROXEN 500MG TAB 500MG 00143134801 · Rx 32826 |
— | 15 / 8 days | 4 of 4 | 2023-12-06 | 2023-12-14 | Overdue |
| JTEST-FLUOXETINE 20MG CAP 20MG 65862019301 · Rx 32828 |
— | 5 / 5 days | 3 of 3 | 2023-12-07 | 2023-12-12 | Overdue |