Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| ADVANCE/PCS | 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 |
|---|---|---|---|---|---|---|
| HALOPERIDOL 1MG TAB 1MG 00378025701 · Rx 57 |
— | 60 / 30 days | 4 of 6 | 2013-02-01 | 2013-03-03 | Overdue |
| LEXAPRO 20MG TAB 20MG 00456202001 · Rx 59 |
— | 30 / 30 days | 1 of 3 | 2007-03-22 | 2007-04-21 | Overdue |
| FLUOXETINE 20MG CAP 20MG 00172435670 · Rx 58 |
— | 30 / 30 days | 1 of 3 | 2007-03-22 | 2007-04-21 | Overdue |
| AMBIEN 10MG TAB 10MG 00024542150 · Rx 66 |
— | 30 / 30 days | 4 of 4 | 2006-06-23 | 2006-07-23 | Overdue |