Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| RELAY TEST PLAN | Primary | ||||
| PRIVATE | PR | Secondary | |||
| RELAY TEST PLAN COPAY | 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 |
|---|---|---|---|---|---|---|
| ALBUTER/IPRATROP 2.5-0.5MG 3ML ALBUTER 69097017364 · Rx 35241 |
— | 30 / 30 days | 0 of 0 | 2025-05-13 | 2025-06-12 | Completed |
| PNEUMOVAX 23 25MCG/.5 INJ 25/0.5 00006494300 · Rx 35036 |
— | 0.5 / 1 days | 0 of 0 | 2025-03-11 | 2025-03-12 | Completed |
| PENICILLN VK 125/5ML SOL 125/5ML 00781612046 · Rx 33330 |
— | 30 / 30 days | 0 of 1 | 2025-01-09 | 2025-02-08 | Completed |
| VITAMIN D 400IU CAP 400UNIT 37205031178 · Rx 33329 |
— | 30 / 30 days | 1 of 1 | 2024-04-16 | 2024-05-16 | Overdue |
| PROZAC 10MG CAP 10MG 00777310402 · Rx 33312 |
— | 30 / 30 days | 1 of 1 | 2024-04-11 | 2024-05-11 | Overdue |
| HYDROXYZ HCL 25MG TAB 25MG 00591552301 · Rx 33323 |
— | 112 / 28 days | 3 of 3 | 2024-04-12 | 2024-05-10 | Overdue |
| TRAZODONE 100MG TAB 100MG 00904399161 · Rx 33322 |
— | 28 / 28 days | 3 of 3 | 2024-04-12 | 2024-05-10 | Overdue |
| FLUOXENTINE 10MG CAP 10MG 00406066101 · Rx 33321 |
— | 28 / 28 days | 3 of 3 | 2024-04-12 | 2024-05-10 | Overdue |
| CLARITIN 10MG TAB 10MG 11523716005 · Rx 33305 |
— | 30 / 30 days | 1 of 1 | 2024-04-10 | 2024-05-10 | Overdue |
| NEOSPORIN GU 40/ML IR SOL 40/ML IR 61570004750 · Rx 33310 |
— | 1 / 1 days | 1 of 1 | 2024-04-11 | 2024-04-12 | Overdue |