Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| RELAY TEST PLAN | 123456 | TESTGRP | 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 |
|---|---|---|---|---|---|---|
| GLYBURIDE 5MG TAB 5MG 51079087320 · Rx 36149 |
— | 7 / 7 days | 2 of 3 | 2026-01-06 | 2026-01-13 | Overdue |
| GABAPENTIN 100MG CAP-APS 100MG 67877022201 · Rx 36123 |
— | 30 / 30 days | 0 of 0 | 2025-11-14 | 2025-12-14 | Completed |
| DIVALPROEX 250MG DR TAB 250MG DR 57237004705 · Rx 36122 |
— | 90 / 30 days | 3 of 3 | 2025-11-14 | 2025-12-14 | Overdue |
| CALCIUM 600MG TAB 600MG 37864073099 · Rx 36121 |
— | 60 / 30 days | 3 of 3 | 2025-11-14 | 2025-12-14 | Overdue |
| VIMPAT 50MG TAB 50MG 00131247735 · Rx 36120 |
— | 30 / 30 days | 1 of 1 | 2025-11-14 | 2025-12-14 | Overdue |
| ALPRAZOLAM 2MG ER TAB 2MG ER 00228308706 · Rx 36119 |
— | 30 / 30 days | 2 of 2 | 2025-11-14 | 2025-12-14 | Overdue |
| VYVANSE 30MG CAP 30MG 59417010310 · Rx 36117 |
— | 30 / 30 days | 0 of 0 | 2025-11-14 | 2025-12-14 | Completed |
| OZEMPIC 2/1.5ML INJ 2/1.5ML 00169413602 · Rx 36129 |
— | 1.5 / 28 days | 3 of 3 | 2025-11-14 | 2025-12-12 | Overdue |
| METFORMIN 1000MG TAB 1000MG 23155010401 · Rx 36148 |
— | 10 / 5 days | 3 of 3 | 2025-11-17 | 2025-11-22 | Overdue |
| APAP/CODEINE 300-30MG TAB 300-30MG 00093015001 · Rx 36118 |
— | 10 / 1 days | 0 of 0 | 2025-11-14 | 2025-11-15 | Completed |
| PSB SYNTHETIC PRODUCT 00093015001 · Rx 36118 |
— | 10 / 1 days | 0 of 0 | 2025-11-14 | 2025-11-15 | Completed |