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 |
|---|---|---|---|---|---|---|
| PYRIDOXAL-5- PHOSPHAT POW PHOSPHAT 49452614804 · Rx 37144 |
Take 1 capsule by mouth twice daily with food | 20 / 90 days | 4 of 4 | 2026-08-20 | 2026-11-18 | Active |
| BUSPIRONE 15MG TAB 15MG 00378116505 · Rx 34711 |
— | 21 / 7 days | 3 of 3 | 2025-02-04 | 2025-02-11 | Overdue |
| CITALOPRAM 40MG TAB 40MG 00378623301 · Rx 34710 |
— | 7 / 7 days | 3 of 3 | 2025-02-04 | 2025-02-11 | Overdue |
| TRAZODONE 100MG TAB 100MG 50111043403 · Rx 34709 |
— | 7 / 7 days | 3 of 3 | 2025-02-04 | 2025-02-11 | Overdue |
| DIVALPROEX 125MG CAP 125MG 68084031301 · Rx 34412 |
— | 28 / 7 days | 3 of 3 | 2024-11-21 | 2024-11-28 | Overdue |
| HYDROCHLOROTHIAZIDE 12.5MG CAP 12.5MG 00591034701 · Rx 34411 |
— | 7 / 7 days | 3 of 3 | 2024-11-21 | 2024-11-28 | Overdue |
| METFORMIN 500MG ER TAB 500MG ER 62037057101 · Rx 34410 |
— | 14 / 7 days | 3 of 3 | 2024-11-21 | 2024-11-28 | Overdue |
| LISINOP-HCTZ 20-12.5 TAB 20-12.5 00172503460 · Rx 34409 |
— | 7 / 7 days | 3 of 3 | 2024-11-21 | 2024-11-28 | Overdue |
| ATORVASTATIN 20MG TAB 20MG 60505257908 · Rx 34408 |
— | 7 / 7 days | 3 of 3 | 2024-11-21 | 2024-11-28 | Overdue |