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 |
|---|---|---|---|---|---|---|
| GABAPENTIN 100MG CAP-APS 100MG 67877022201 · Rx 34588 |
— | 30 / 30 days | 1 of 4 | 2025-11-05 | 2025-12-05 | Overdue |
| DIVALPROEX 250MG DR TAB 250MG DR 57237004705 · Rx 34587 |
— | 90 / 30 days | 1 of 3 | 2025-11-05 | 2025-12-05 | Overdue |
| CALCIUM 600MG TAB 600MG 37864073099 · Rx 34586 |
— | 60 / 30 days | 1 of 3 | 2025-08-01 | 2025-08-31 | Overdue |
| SPRAVATO 56MG DOS SOL 56MG DOS 50458002802 · Rx 34908 |
— | 2 / 1 days | 1 of 1 | 2025-02-25 | 2025-02-26 | Overdue |
| QUILLIVANT XR SUS 25MG/5ML 24478032305 · Rx 34640 |
— | 150 / 30 days | 0 of 0 | 2025-01-24 | 2025-02-23 | Completed |
| SELEGILINE 5MG TAB 5MG 60505343803 · Rx 34596 |
— | 30 / 30 days | 3 of 3 | 2025-01-15 | 2025-02-14 | Overdue |
| ALPRAZOLAM 2MG ER TAB 2MG ER 65162081206 · Rx 34585 |
— | 30 / 30 days | 2 of 2 | 2025-01-15 | 2025-02-14 | Overdue |
| VYVANSE 30MG CAP 30MG 59417010310 · Rx 34583 |
— | 30 / 30 days | 0 of 0 | 2025-01-15 | 2025-02-14 | Completed |
| GABAPENTIN 600MG TAB 340B 600MG 68462012601 · Rx 34682 |
— | 10 / 10 days | 3 of 3 | 2025-01-30 | 2025-02-09 | Overdue |
| VYVANSE 20MG CAP 20MG 59417010210 · Rx 34637 |
— | 7 / 7 days | 0 of 0 | 2025-01-23 | 2025-01-30 | Completed |
| ALPRAZOLAM 0.25MG TAB 0.25MG 00228202710 · Rx 34577 |
— | 15 / 15 days | 3 of 3 | 2025-01-14 | 2025-01-29 | Overdue |
| GABAPENTIN 100MG CAP-APS 100MG 67877022201 · Rx 34579 |
— | 7 / 7 days | 3 of 3 | 2025-01-14 | 2025-01-21 | Overdue |
| SELEGILINE 5MG TAB 5MG 60505343803 · Rx 34597 |
— | 30 / 1 days | 3 of 3 | 2025-01-15 | 2025-01-16 | Overdue |
| SPRAVATO 56MG DOS SOL 56MG DOS 50458002802 · Rx 34595 |
— | 2 / 1 days | 3 of 3 | 2025-01-15 | 2025-01-16 | Overdue |
| AMPHETAMINE SALT 25MG *ER* CAP 25MG ER 66993059802 · Rx 34594 |
test notes here | 7 / 1 days | 0 of 0 | 2025-01-15 | 2025-01-16 | Completed |
| APAP/CODEINE 300-30MG TAB 300-30MG 00093015001 · Rx 34584 |
— | 10 / 1 days | 0 of 0 | 2025-01-15 | 2025-01-16 | Completed |
| PSB SYNTHETIC PRODUCT 00093015001 · Rx 34584 |
— | 10 / 1 days | 0 of 0 | 2025-01-15 | 2025-01-16 | Completed |