Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| CHANGE HEALTHCARE | 123 | Secondary | |||
| PRIVATE | PR | 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 |
|---|---|---|---|---|---|---|
| NADOLOL 20MG TAB 20MG 69097086707 · Rx 36284 |
— | 7 / 7 days | 0 of 3 | 2025-12-10 | 2025-12-17 | Completed |
| TRAZODONE 150MG TAB 150MG 60505265501 · Rx 36275 |
— | 7 / 7 days | 95 of 99 | 2025-12-10 | 2025-12-17 | Overdue |
| HALDOL 0.5MG TAB 0.5MG 00045024060 · Rx 36296 |
— | 5 / 5 days | 10 of 10 | 2025-12-10 | 2025-12-15 | Overdue |
| HALDOL 0.5MG TAB 0.5MG 00045024060 · Rx 36277 |
— | 5 / 5 days | 9 of 10 | 2025-12-09 | 2025-12-14 | Overdue |
| SPRAVATO 56MG DOS SOL 56MG DOS 50458002802 · Rx 36294 |
— | 3 / 3 days | 1 of 1 | 2025-12-10 | 2025-12-13 | Overdue |
| SAM-LATUDA 120MG TAB 120MG 63402031230 · Rx 36305 |
— | 1 / 1 days | 10 of 10 | 2025-12-11 | 2025-12-12 | Overdue |
| VESICARE 10MG TAB 10MG 51248015101 · Rx 36304 |
— | 1 / 1 days | 10 of 10 | 2025-12-11 | 2025-12-12 | Overdue |
| COGENTIN 1MG TAB 1MG 00006006069 · Rx 36303 |
— | 1 / 1 days | 98 of 99 | 2025-12-11 | 2025-12-12 | Overdue |
| WELLBUTRIN 100MG SR TAB 100MG SR 00173094755 · Rx 36302 |
— | 1 / 1 days | 10 of 10 | 2025-12-11 | 2025-12-12 | Overdue |
| COGENTIN 1MG TAB 1MG 00006006069 · Rx 36300 |
— | 1 / 1 days | 97 of 99 | 2025-12-10 | 2025-12-11 | Overdue |
| SEROQUEL 100MG TAB 100MG 00310027110 · Rx 36299 |
— | 1 / 1 days | 99 of 99 | 2025-12-10 | 2025-12-11 | Overdue |
| ISORDIL 5MG TAB 5MG 64455015201 · Rx 36298 |
— | 1 / 1 days | 99 of 99 | 2025-12-10 | 2025-12-11 | Overdue |
| STRATTERA 100MG CAP 100MG 00002325130 · Rx 36297 |
— | 1 / 1 days | 99 of 99 | 2025-12-10 | 2025-12-11 | Overdue |
| VERAPAMIL 100MG ER CAP-APS 100MG ER 00378620101 · Rx 36295 |
— | 1 / 1 days | 98 of 99 | 2025-12-10 | 2025-12-11 | Overdue |
| STADOL 1MG/ML INJ 1MG/ML 00015564515 · Rx 36289 |
— | 1 / 1 days | 4 of 5 | 2025-12-10 | 2025-12-11 | Overdue |
| STRATTERA 100MG CAP 100MG 00002325130 · Rx 36281 |
— | 1 / 1 days | 97 of 99 | 2025-12-10 | 2025-12-11 | Overdue |