Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| PRIVATE | PR | Secondary | |||
| RELAY TEST PLAN COPAY | Secondary | ||||
| RELAY TEST PLAN | Secondary | ||||
| YESSICA'S TEST OPEN ITEM | 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 |
|---|---|---|---|---|---|---|
| OZEMPIC 2/1.5ML INJ 2/1.5ML 00169413611 · Rx 36057 |
— | 1.5 / 28 days | 3 of 3 | 2025-10-31 | 2025-11-28 | Overdue |
| VITAMIN D 1000 UNIT TAB 1000UNIT 00536333401 · Rx 36022 |
— | 7 / 7 days | 1 of 5 | 2025-10-31 | 2025-11-07 | Overdue |
| ATOMOXETINE HCL 100MG CAP 100MG 68462027130 · Rx 36021 |
— | 7 / 7 days | 2 of 3 | 2025-10-31 | 2025-11-07 | Overdue |
| INTUNIV 4MG TAB 4MG 54092051902 · Rx 36054 |
— | 1 / 1 days | 99 of 99 | 2025-10-29 | 2025-10-30 | Overdue |
| INTUNIV 4MG TAB 4MG 54092051902 · Rx 36020 |
— | 7 / 7 days | 0 of 3 | 2025-10-23 | 2025-10-30 | Completed |