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 |
|---|---|---|---|---|---|---|
| AMITRIPTYLIN 25MG TAB 25MG 53489010501 · Rx 36152 |
— | 7 / 7 days | 3 of 3 | 2025-11-18 | 2025-11-25 | Overdue |
| JTEST-TRAZODONE 50MG TAB 50MG 50111043303 · Rx 36151 |
— | 7 / 7 days | 3 of 3 | 2025-11-18 | 2025-11-25 | Overdue |
| NAPROXEN 500MG TAB 500MG 68462019001 · Rx 33884 |
— | 28 / 28 days | 2 of 3 | 2025-08-01 | 2025-08-29 | Overdue |
| VITAMIN E 200IU CAP 200UNIT 00182007901 · Rx 33883 |
— | 28 / 28 days | 2 of 3 | 2025-08-01 | 2025-08-29 | Overdue |
| MODERNA COVID BIVAL BSTR 0.5ML BA4/BA5 80777028299 · Rx 35022 |
— | 0.5 / 1 days | 0 of 0 | 2025-03-10 | 2025-03-11 | Completed |
| ABILIFY 20MG TAB 20MG 59148001013 · Rx 33959 |
— | 15 / 15 days | 1 of 1 | 2024-08-23 | 2024-09-07 | Overdue |
| FLULAVAL PFS 2024-25 2024-25 19515081052 · Rx 34001 |
— | 0.5 / 1 days | 0 of 0 | 2024-08-30 | 2024-08-31 | Completed |
| VYVANSE 70MG CAP 70MG 59417010710 · Rx 33839 |
— | 1 / 1 days | 0 of 1 | 2024-08-13 | 2024-08-14 | Completed |
| ARIPIPRAZOLE 20MG TAB 20MG 65162090109 · Rx 33283 |
— | 28 / 28 days | 3 of 3 | 2024-03-29 | 2024-04-26 | Overdue |