Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| PRIVATE | PR | Secondary | |||
| RELAY TEST PLAN COPAY | 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 |
|---|---|---|---|---|---|---|
| ESOMEPRA MAG 40MG DR CAP 40MG DR 13668015530 · Rx 35735 |
— | 10 / 10 days | 3 of 3 | 2026-04-15 | 2026-04-25 | Overdue |
| ALCOHOL PADS 00000001104 · Rx 35730 |
— | 100 / 100 days | 5 of 5 | 2025-07-30 | 2025-11-07 | Overdue |
| SAM-E 400MG TAB 400MG 74312013185 · Rx 35932 |
— | 30 / 30 days | 1 of 1 | 2025-09-12 | 2025-10-12 | Overdue |
| ALCOHOL PADS 00000001104 · Rx 35886 |
— | 25 / 25 days | 1 of 1 | 2025-09-09 | 2025-10-04 | Overdue |
| TRAZODONE 150MG TAB 150MG 60505265501 · Rx 35884 |
— | 1 / 7 days | 3 of 3 | 2025-09-09 | 2025-09-16 | Overdue |
| COTTON BALLS MIS 87701024760 · Rx 35885 |
— | 5 / 5 days | 3 of 3 | 2025-09-09 | 2025-09-14 | Overdue |
| TYLENOL ARTH 650MG TAB 650MG 50580011210 · Rx 35435 |
— | 2 / 31 days | 4 of 4 | 2025-06-16 | 2025-07-17 | Overdue |
| TYLENOL ARTH 650MG TAB 650MG 50580011210 · Rx 35434 |
— | 2 / 31 days | 1 of 1 | 2025-06-16 | 2025-07-17 | Overdue |
| JARDIANCE 10MG TAB 10MG 00597015230 · Rx 34891 |
— | 21 / 11 days | 1 of 1 | 2025-02-25 | 2025-03-08 | Overdue |
| PNEUMOVAX 23 25MCG/.5 INJ 25/0.5 00006494300 · Rx 34978 |
— | 0.5 / 1 days | 0 of 0 | 2025-03-06 | 2025-03-07 | Completed |
| MODERNA COVID BIVAL BSTR 0.5ML BA4/BA5 80777028299 · Rx 34977 |
— | 0.5 / 1 days | 0 of 0 | 2025-03-06 | 2025-03-07 | Completed |
| ZOKINVY 50MG CAP 50MG 73079005030 · Rx 34150 |
— | 20 / 20 days | 0 of 0 | 2024-10-09 | 2024-10-29 | Completed |
| ZOKINVY 50MG CAP 50MG 73079005030 · Rx 34145 |
— | 30 / 15 days | 2 of 2 | 2024-10-07 | 2024-10-22 | Overdue |
| PAROXETINE 10MG TAB 10MG 49884087611 · Rx 19811 |
— | 90 / 30 days | 2 of 2 | 2009-12-03 | 2010-01-02 | Overdue |
| PAROXETINE 10MG TAB 10MG 49884087611 · Rx 624 |
— | 90 / 30 days | 2 of 2 | 2007-10-12 | 2007-11-11 | Overdue |
| PAROXETINE 10MG TAB 10MG 49884087611 · Rx 123 |
— | 90 / 30 days | 2 of 2 | 2006-09-21 | 2006-10-21 | Overdue |
| DIGITEK 0.125MG TAB 0.125MG 62794014501 · Rx 131 |
— | 20 / 20 days | 1 of 1 | 2006-09-22 | 2006-10-12 | Overdue |
| ASPIR-LOW 81MG EC TAB 81MG EC 00904770418 · Rx 130 |
— | 20 / 20 days | 1 of 1 | 2006-09-22 | 2006-10-12 | Overdue |
| COUMADIN 10MG TAB 10MG 00056017470 · Rx 129 |
— | 20 / 20 days | 1 of 1 | 2006-09-22 | 2006-10-12 | Overdue |
| DEPAKOTE EC 500MG TAB 500MG DR 00074621513 · Rx 90 |
— | 90 / 30 days | 0 of 0 | 2006-08-22 | 2006-09-21 | Completed |
| PAP-ABILIFY 15MG TAB 15MG 59148000913 · Rx 89 |
— | 60 / 30 days | 0 of 0 | 2006-08-22 | 2006-09-21 | Completed |
| ZYPREXA 5MG TAB 5MG 00002411530 · Rx 88 |
— | 30 / 30 days | 0 of 0 | 2006-08-22 | 2006-09-21 | Completed |