Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| RELAY TEST PLAN | UATTEST | Primary | |||
| PRIVATE | PR | Secondary | |||
| RELAY TEST PLAN COPAY | 1234 | 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 |
|---|---|---|---|---|---|---|
| TOPIRAMATE 100MG TAB 100MG 69097012415 · Rx 37072 |
— | 10 / 10 days | 1 of 1 | 2026-07-27 | 2026-08-06 | Overdue |
| MIRTAZAPINE 30MG TAB 30MG 00093720756 · Rx 37069 |
— | 7 / 7 days | 10 of 10 | 2026-07-27 | 2026-08-03 | Overdue |
| HYDROXYZ PAM 25MG CAP 25MG 00555032304 · Rx 36670 |
— | 18 / 9 days | 1 of 1 | 2026-04-10 | 2026-04-19 | Overdue |
| VIMPAT 50MG TAB 50MG 00131247735 · Rx 35938 |
— | 30 / 30 days | 0 of 1 | 2025-11-07 | 2025-12-07 | Completed |
| GABAPENTIN 100MG CAP 100MG 00228266511 · Rx 35937 |
— | 30 / 30 days | 0 of 0 | 2025-11-07 | 2025-12-07 | Completed |
| CALCIUM 600MG TAB 00536342608 · Rx 35936 |
— | 60 / 30 days | 2 of 3 | 2025-11-07 | 2025-12-07 | Overdue |
| TRAZODONE 150MG TAB 150MG 60505265501 · Rx 36139 |
— | 7 / 7 days | 3 of 3 | 2025-11-17 | 2025-11-24 | Overdue |
| HALDOL 10MG TAB 10MG 00045024660 · Rx 35820 |
— | 7 / 7 days | 2 of 3 | 2025-11-17 | 2025-11-24 | Overdue |
| GAUZE 2"X2" PAD 2"X2" 11917005254 · Rx 35818 |
— | 30 / 30 days | 1 of 1 | 2025-08-06 | 2025-09-05 | Overdue |
| COTTON BALLS MIS 87701024760 · Rx 35819 |
— | 300 / 25 days | 1 of 1 | 2025-08-06 | 2025-08-31 | Overdue |
| DIVALPROEX 250MG DR TAB 250MG DR 57237004701 · Rx 35237 |
— | 90 / 30 days | 1 of 3 | 2025-06-03 | 2025-07-03 | Overdue |
| CALCIUM 600MG TAB 600MG 37864073099 · Rx 35236 |
— | 60 / 30 days | 2 of 3 | 2025-05-30 | 2025-06-29 | Overdue |
| GABAPENTIN 100MG CAP-APS 100MG 67877022201 · Rx 35238 |
— | 30 / 30 days | 0 of 0 | 2025-05-12 | 2025-06-11 | Completed |
| VIMPAT 50MG TAB 50MG 00131247735 · Rx 35235 |
— | 30 / 30 days | 1 of 1 | 2025-05-12 | 2025-06-11 | Overdue |
| ALPRAZOLAM 2MG ER TAB 2MG ER 00228308706 · Rx 35234 |
— | 30 / 30 days | 2 of 2 | 2025-05-12 | 2025-06-11 | Overdue |
| VYVANSE 30MG CAP 30MG 59417010310 · Rx 35232 |
— | 30 / 30 days | 0 of 0 | 2025-05-12 | 2025-06-11 | Completed |
| APAP/CODEINE 300-30MG TAB 300-30MG 00093015001 · Rx 35233 |
— | 10 / 1 days | 0 of 0 | 2025-05-12 | 2025-05-13 | Completed |
| PSB SYNTHETIC PRODUCT 00093015001 · Rx 35233 |
— | 10 / 1 days | 0 of 0 | 2025-05-12 | 2025-05-13 | Completed |
| DRONABINOL 10MG CAP 10MG 49884086902 · Rx 33388 |
— | 2 / 2 days | 0 of 0 | 2024-04-29 | 2024-05-01 | Completed |
| OLMESARTAN MEDOXOMIL 20MG TAB 20MG 57664075699 · Rx 33389 |
— | 1 / 1 days | 2 of 3 | 2024-04-29 | 2024-04-30 | Overdue |