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 |
|---|---|---|---|---|---|---|
| FISH OIL 1000MG CAP 1000MG 11845014957 · Rx 36996 |
— | 60 / 60 days | 0 of 0 | 2026-06-23 | 2026-08-22 | Completed |
| CHLORPROMAZ 100MG TAB 100MG 51079051620 · Rx 37063 |
— | 10 / 10 days | 1 of 1 | 2026-07-24 | 2026-08-03 | Overdue |
| CHLORZOXAZON 500MG TAB 500MG 00591252001 · Rx 37064 |
— | 10 / 5 days | 1 of 1 | 2026-07-24 | 2026-07-29 | Overdue |
| GAVISCON 80-20MG TAB 00088117547 · Rx 36994 |
— | 10 / 10 days | 0 of 0 | 2026-06-23 | 2026-07-03 | Completed |
| BANDAID JJ BANDAID JJ · Rx 36992 |
— | 10 / 10 days | 0 of 0 | 2026-06-23 | 2026-07-03 | Completed |
| DIPHENHYDRAM 25MG CAP 25MG 00182049210 · Rx 36991 |
— | 10 / 10 days | 0 of 0 | 2026-06-23 | 2026-07-03 | Completed |
| HALDOL 0.5MG TAB 0.5MG 00045024060 · Rx 36990 |
— | 10 / 10 days | 5 of 5 | 2026-06-23 | 2026-07-03 | Overdue |
| SOLIFENACIN 5MG TAB 5MG 00093526356 · Rx 36988 |
— | 5 / 5 days | 1 of 1 | 2026-06-23 | 2026-06-28 | Overdue |
| CARBAMAZEPIN 200MG TAB 200MG 13668026805 · Rx 36501 |
— | 7 / 7 days | 1 of 1 | 2026-02-24 | 2026-03-03 | Overdue |
| GABAPENTIN 100MG CAP-APS 100MG 14550051104 · Rx 36500 |
— | 7 / 1 days | 1 of 1 | 2026-02-24 | 2026-02-25 | Overdue |
| MAPAP 500MG TAB 500MG 00904198340 · Rx 36265 |
— | 30 / 30 days | 10 of 10 | 2025-12-03 | 2026-01-02 | Overdue |
| PALIPERIDONE ER 1.5MG TAB ER 1.5MG 10147095103 · Rx 36235 |
— | 30 / 30 days | 3 of 3 | 2025-11-25 | 2025-12-25 | Overdue |
| MAPAP 500MG TAB 500MG 00904198380 · Rx 36260 |
— | 10 / 10 days | 5 of 5 | 2025-12-02 | 2025-12-12 | Overdue |
| LISINOPRIL 10MG TAB 10MG 68180051401 · Rx 36258 |
— | 1 / 1 days | 1 of 1 | 2025-12-02 | 2025-12-03 | Overdue |