Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| PRIVATE | PR | 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 |
|---|---|---|---|---|---|---|
| IPRATROPIUM/ ALBUTER SOL ALBUTER 76204060030 · Rx 36134 |
— | 90 / 30 days | 3 of 3 | 2025-11-16 | 2025-12-16 | Overdue |
| SAM-LATUDA 120MG TAB 120MG 63402031230 · Rx 34695 |
— | 7 / 7 days | 2 of 3 | 2025-11-16 | 2025-11-23 | Overdue |
| VENTOLIN HFA AER 00173068224 · Rx 36135 |
— | 8 / 5 days | 5 of 5 | 2025-11-16 | 2025-11-21 | Overdue |
| THYROID 130MG TAB 130MG 00677165910 · Rx 33463 |
— | 28 / 28 days | 1 of 2 | 2025-08-01 | 2025-08-29 | Overdue |
| FLONASE ALGY 50MCG SPR 50MCG 00135057604 · Rx 33461 |
— | 28 / 28 days | 0 of 1 | 2025-08-01 | 2025-08-29 | Completed |
| TYLENOL ARTH 650MG TAB 650MG 50580011225 · Rx 33462 |
— | 28 / 14 days | 0 of 0 | 2024-05-16 | 2024-05-30 | Completed |