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 |
|---|---|---|---|---|---|---|
| JTEST-TRAZODONE 50MG TAB 50MG 50111043303 · Rx 34182 |
— | 14 / 14 days | 1 of 3 | 2025-08-01 | 2025-08-15 | Overdue |
| PANTOPRAZOLE 40MG TAB 40MG 65862056090 · Rx 34181 |
— | 14 / 14 days | 1 of 4 | 2025-08-01 | 2025-08-15 | Overdue |
| DIVALPROEX 125MG CAP 125MG 68084031301 · Rx 34183 |
— | 14 / 5 days | 1 of 3 | 2025-08-01 | 2025-08-06 | Overdue |
| GUANFACINE 1MG **ER** TAB 1MG ER 00781545101 · Rx 35117 |
— | 14 / 14 days | 2 of 3 | 2025-06-05 | 2025-06-19 | Overdue |
| BUSPIRONE 10MG TAB 10MG 00378115001 · Rx 35336 |
— | 21 / 7 days | 10 of 10 | 2025-06-05 | 2025-06-12 | Overdue |
| LITHIUM CARB 300MG CAP 300MG 68462022110 · Rx 35335 |
— | 7 / 7 days | 3 of 3 | 2025-06-05 | 2025-06-12 | Overdue |
| STRATTERA 100MG CAP 100MG 00002325130 · Rx 35118 |
— | 14 / 14 days | 0 of 0 | 2025-03-18 | 2025-04-01 | Completed |
| VIMPAT 10MG/ML SOL 10MG/ML 00131541070 · Rx 34288 |
— | 30 / 30 days | 0 of 0 | 2024-11-05 | 2024-12-05 | Completed |