Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| PRIVATE | PR | Secondary | |||
| RELAY TEST PLAN | TESTID | TESTGRP | 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 |
|---|---|---|---|---|---|---|
| PROPRANOLOL 10MG TAB 10MG 00115165901 · Rx 36980 |
— | 60 / 30 days | 6 of 6 | 2026-06-23 | 2026-07-23 | Overdue |
| ISOSORB DIN 40MG ER TAB 40MG ER 57664060088 · Rx 36981 |
— | 10 / 10 days | 5 of 5 | 2026-06-23 | 2026-07-03 | Overdue |
| GABAPENTIN 100MG CAP 100MG 00228266511 · Rx 35946 |
— | 30 / 30 days | 0 of 0 | 2025-09-12 | 2025-10-12 | Completed |
| DIVALPROEX 250MG DR TAB 250MG DR 00832712315 · Rx 35945 |
— | 90 / 30 days | 3 of 3 | 2025-09-12 | 2025-10-12 | Overdue |
| CALCIUM 600MG TAB 600MG 37864073099 · Rx 35944 |
— | 60 / 30 days | 3 of 3 | 2025-09-12 | 2025-10-12 | Overdue |
| PENICILLN VK 125/5ML SOL 125/5ML 00781612046 · Rx 33651 |
— | 28 / 28 days | 2 of 3 | 2024-10-22 | 2024-11-19 | Overdue |
| FAMOTIDINE 20MG TAB 20MG 00093089601 · Rx 33653 |
— | 28 / 14 days | 1 of 2 | 2024-10-22 | 2024-11-05 | Overdue |
| LEVOTHYROXIN 137MCG TAB 137MCG 00781519101 · Rx 33654 |
— | 30 / 30 days | 0 of 0 | 2024-06-26 | 2024-07-26 | Completed |
| NEOSPORIN GU 40/ML IR SOL 40/ML IR 61570004750 · Rx 33652 |
— | 28 / 28 days | 0 of 0 | 2024-06-26 | 2024-07-24 | Completed |