Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| PATIENT ASSISTANCE PROGRA | 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 |
|---|---|---|---|---|---|---|
| GREEN SKITTLES GREEN8 34387812341 · Rx 28329 |
— | 90 / 30 days | 0 of 0 | 2016-11-29 | 2016-12-29 | Completed |
| YELLOW SKITTLES YELLOW3 23487874238 · Rx 28334 |
— | 112 / 28 days | 0 of 0 | 2016-11-29 | 2016-12-27 | Completed |
| RED SKITTLES RED7 24234234234 · Rx 28333 |
— | 56 / 28 days | 0 of 0 | 2016-11-29 | 2016-12-27 | Completed |
| ORANGE SKITTLES ORANGE5 89898989834 · Rx 28332 |
— | 28 / 28 days | 0 of 0 | 2016-11-29 | 2016-12-27 | Completed |
| PURPLE SKITTLES PURPLE1 34384938423 · Rx 28331 |
— | 56 / 28 days | 0 of 0 | 2016-11-29 | 2016-12-27 | Completed |
| METFORMIN 1000MG TAB 1000MG 65862001005 · Rx 28050 |
— | 60 / 30 days | 0 of 0 | 2016-09-07 | 2016-10-07 | Completed |
| GREEN JELLY BEAN 98777777777 · Rx 28009 |
— | 28 / 28 days | 0 of 0 | 2016-08-23 | 2016-09-20 | Completed |
| GREEN JELLY BEAN 98777777777 · Rx 28005 |
— | 56 / 28 days | 0 of 0 | 2016-08-23 | 2016-09-20 | Completed |
| YELLOW CANDY 0 00010101010 · Rx 28004 |
— | 28 / 28 days | 0 of 0 | 2016-08-23 | 2016-09-20 | Completed |
| HOT TAMLES RED HOT 43289472344 · Rx 28003 |
— | 28 / 28 days | 0 of 0 | 2016-08-23 | 2016-09-20 | Completed |
| WHITE CANDY 12334456631 · Rx 28002 |
— | 56 / 28 days | 0 of 0 | 2016-08-23 | 2016-09-20 | Completed |
| YELLOW CANDY 0 00010101010 · Rx 28001 |
— | 28 / 28 days | 2 of 2 | 2016-08-23 | 2016-09-20 | Overdue |
| GREEN CANDY OBLONG 23094283094 · Rx 27998 |
— | 28 / 28 days | 1 of 1 | 2016-08-22 | 2016-09-19 | Overdue |
| GREEN JELLY BEAN 98777777777 · Rx 27997 |
— | 56 / 28 days | 5 of 5 | 2016-08-22 | 2016-09-19 | Overdue |
| WHITE CANDY 10101010000 · Rx 27995 |
— | 28 / 7 days | 0 of 0 | 2016-08-22 | 2016-08-29 | Completed |
| RED OBLONG CANDY 12345688990 · Rx 27799 |
— | 56 / 28 days | 3 of 3 | 2016-06-07 | 2016-07-05 | Overdue |
| BROWN CANDY CANDY 99999999555 · Rx 27798 |
— | 112 / 28 days | 3 of 3 | 2016-06-07 | 2016-07-05 | Overdue |
| YELLOW CANDY 0 00010101010 · Rx 27797 |
— | 28 / 28 days | 3 of 3 | 2016-06-07 | 2016-07-05 | Overdue |
| ORANGE CANDY 63492834792 · Rx 27796 |
— | 84 / 28 days | 3 of 3 | 2016-06-07 | 2016-07-05 | Overdue |
| WHITE CANDY 12334456631 · Rx 27795 |
— | 112 / 28 days | 3 of 3 | 2016-06-07 | 2016-07-05 | Overdue |
| APS-ABILIFY 10MG TAB 10MG 59148000813 · Rx 26695 |
— | 30 / 30 days | 2 of 2 | 2015-04-30 | 2015-05-30 | Overdue |
| PAP-ABILIFY 10MG TAB 10MG 59148000899 · Rx 21310 |
— | 30 / 30 days | 5 of 5 | 2011-08-01 | 2011-08-31 | Overdue |
| ASPIR-LOW 81MG EC TAB 81MG EC 00904770418 · Rx 21308 |
test | 30 / 30 days | 5 of 5 | 2011-07-29 | 2011-08-28 | Overdue |
| IBUPROFEN 200MG TAB 200MG 65162056550 · Rx 21307 |
— | 60 / 30 days | 5 of 5 | 2011-07-29 | 2011-08-28 | Overdue |
| SERTRALINE 50MG TAB 50MG 00378418793 · Rx 20899 |
— | 30 / 30 days | 3 of 5 | 2011-06-21 | 2011-07-21 | Overdue |
| OXYCONTIN 20MG CR TAB 20MG CR 59011010310 · Rx 20898 |
— | 30 / 30 days | 0 of 0 | 2011-06-13 | 2011-07-13 | Completed |
| SERTRALINE 100MG TAB 100MG 00378418805 · Rx 20897 |
— | 30 / 30 days | 5 of 5 | 2011-06-13 | 2011-07-13 | Overdue |
| IBUPROFEN 200MG TAB 200MG 54569410200 · Rx 20886 |
— | 30 / 30 days | 4 of 5 | 2011-06-13 | 2011-07-13 | Overdue |
| ABILIFY 30MG TAB 30MG 59148001113 · Rx 20896 |
— | 30 / 30 days | 5 of 5 | 2011-06-12 | 2011-07-12 | Overdue |
| OXYCONTIN 80MG CR TAB 80MG CR 54868398601 · Rx 20887 |
— | 30 / 30 days | 0 of 0 | 2011-06-08 | 2011-07-08 | Completed |
| GEODON 20MG CAP 20MG 00049396060 · Rx 20684 |
— | 30 / 30 days | 1 of 2 | 2011-05-31 | 2011-06-30 | Overdue |
| LITHIUM CARB 150MG CAP 150MG 00054252625 · Rx 20683 |
— | 60 / 30 days | 2 of 2 | 2011-04-13 | 2011-05-13 | Overdue |