Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| RELAY TEST PLAN | Primary | ||||
| ALL MEDICARE | Secondary | ||||
| CHANGE HEALTHCARE | 123 | 456 | Secondary | ||
| MED B CLAIMS | Secondary | ||||
| PRIVATE | PR | 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 |
|---|---|---|---|---|---|---|
| INVEGA SUST 234MG/1.5 INJ 234/1.5 50458056401 · Rx 36497 |
— | 1.5 / 28 days | 0 of 1 | 2026-02-24 | 2026-03-24 | Completed |
| INVEGA 1.5MG TAB 1.5MG 50458055401 · Rx 36498 |
— | 0.75 / 1 days | 2 of 3 | 2026-02-24 | 2026-02-25 | Overdue |
| CHOLESTYRAMINE 4GM POWDER 4GM 49884046565 · Rx 35345 |
— | 60 / 30 days | 3 of 3 | 2025-06-06 | 2025-07-06 | Overdue |
| DIAZEPAM 2MG TAB 2MG 00172392560 · Rx 35419 |
— | 10 / 10 days | 3 of 3 | 2025-06-13 | 2025-06-23 | Overdue |
| TRAZODONE 50MG TAB 50MG 60505265301 · Rx 35350 |
— | 7 / 7 days | 3 of 3 | 2025-06-06 | 2025-06-13 | Overdue |
| TRAZODONE 150MG TAB 150MG 50111044102 · Rx 34485 |
— | 7 / 7 days | 3 of 3 | 2025-06-06 | 2025-06-13 | Overdue |
| DIVALPROEX 125MG EC TAB 125MG DR 62756079688 · Rx 34484 |
— | 14 / 7 days | 3 of 3 | 2025-06-06 | 2025-06-13 | Overdue |
| SPIRIVA HANDIHLR CAP HANDIHLR 00597007575 · Rx 35348 |
— | 5 / 5 days | 2 of 2 | 2025-06-06 | 2025-06-11 | Overdue |
| APS-ABILIFY 10MG TAB 10MG 59148000813 · Rx 35346 |
— | 10 / 5 days | 0 of 0 | 2025-06-06 | 2025-06-11 | Completed |
| TRAZODONE 100MG TAB 100MG 50111043403 · Rx 34581 |
— | 7 / 7 days | 2 of 3 | 2025-05-23 | 2025-05-30 | Overdue |
| ALLOPURINOL 100MG TAB 100MG 00378013701 · Rx 34715 |
— | 7 / 7 days | 3 of 3 | 2025-02-04 | 2025-02-11 | Overdue |
| FAMOTIDINE 40MG TAB 40MG 64679093702 · Rx 34486 |
— | 7 / 7 days | 3 of 3 | 2025-01-08 | 2025-01-15 | Overdue |
| RISPERDAL 0.25MG TAB 0.25MG 50458030104 · Rx 34173 |
— | 30 / 30 days | 0 of 0 | 2024-10-18 | 2024-11-17 | Completed |
| ROSUVASTATIN 20MG TAB 20MG 00781540292 · Rx 34164 |
— | 30 / 30 days | 3 of 3 | 2024-10-17 | 2024-11-16 | Overdue |
| TRAZODONE 100MG TAB 100MG 50111043402 · Rx 33338 |
— | 30 / 30 days | 3 of 3 | 2024-04-20 | 2024-05-20 | Overdue |
| NEBULIZER KIT 73796039000 · Rx 33332 |
— | 1 / 30 days | 0 of 0 | 2024-04-18 | 2024-05-18 | Completed |
| ONE TOUCH UL STRIPS TES ULTRA 53885024510 · Rx 33350 |
— | 100 / 25 days | 3 of 3 | 2024-04-22 | 2024-05-17 | Overdue |
| LANCETS MIS 38415010028 · Rx 33346 |
— | 100 / 25 days | 3 of 3 | 2024-04-22 | 2024-05-17 | Overdue |
| ONE TOUCH ULTRA KIT ULTRA 53885024701 · Rx 33351 |
— | 1 / 1 days | 4 of 5 | 2024-04-23 | 2024-04-24 | Overdue |
| NEBULIZER KIT 73796039000 · Rx 33333 |
— | 1 / 1 days | 0 of 1 | 2024-04-19 | 2024-04-20 | Completed |