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 |
|---|---|---|---|---|---|---|
| FUROSEMIDE 20MG TAB 20MG 63304062401 · Rx 35795 |
— | 30 / 30 days | 0 of 0 | 2025-08-05 | 2025-09-04 | Completed |
| FLONASE 0.05% SPR 0.05% 00173045301 · Rx 35804 |
— | 28 / 28 days | 1 of 1 | 2025-08-06 | 2025-09-03 | Overdue |
| THYROID 130MG TAB 130MG 00677165910 · Rx 35803 |
— | 7 / 7 days | 1 of 1 | 2025-08-06 | 2025-08-13 | Overdue |
| THYROID 130MG TAB 130MG 00677165910 · Rx 34049 |
— | 7 / 7 days | 1 of 1 | 2025-07-14 | 2025-07-21 | Overdue |
| PFIZER COVID BIVAL BSTR BA4/BA5 59267030402 · Rx 34962 |
— | 0.3 / 1 days | 0 of 0 | 2025-03-06 | 2025-03-07 | Completed |
| METFORMIN 1000MG ER TAB 1000MG 65162017750 · Rx 34528 |
— | 30 / 30 days | 3 of 3 | 2025-01-07 | 2025-02-06 | Overdue |
| PIOGLITAZONE 15MG TAB 15MG 00378004877 · Rx 34511 |
— | 7 / 7 days | 3 of 3 | 2025-01-06 | 2025-01-13 | Overdue |
| LATANOPROST 0.005% SOL 0.005% 00517083001 · Rx 33467 |
— | 28 / 28 days | 0 of 1 | 2024-10-28 | 2024-11-25 | Completed |
| FLONASE ALGY 50MCG SPR 50MCG 00135057603 · Rx 33464 |
— | 28 / 28 days | 0 of 1 | 2024-10-28 | 2024-11-25 | Completed |
| THYROID 130MG TAB 130MG 00677165910 · Rx 33466 |
— | 28 / 28 days | 1 of 1 | 2024-05-16 | 2024-06-13 | Overdue |
| TYLENOL ARTH 650MG TAB 650MG 50580011210 · Rx 33465 |
— | 28 / 28 days | 0 of 0 | 2024-05-16 | 2024-06-13 | Completed |