Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| ADVANCE/PCS | Secondary | ||||
| CHANGE HEALTHCARE | TESTID123 | TESTGROUP456 | Secondary | ||
| COLORADO MEDICAID 1 | Secondary | ||||
| 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 |
|---|---|---|---|---|---|---|
| GABAPENTIN 100MG CAP 100MG 59762502601 · Rx 35816 |
— | 30 / 30 days | 0 of 0 | 2026-02-11 | 2026-03-13 | Completed |
| CALCIUM 600MG TAB 600MG 37864073099 · Rx 35814 |
— | 60 / 30 days | 3 of 3 | 2026-02-11 | 2026-03-13 | Overdue |
| BUPROPN HCL 150MG XL TAB 150MG XL 50228014430 · Rx 36463 |
— | 7 / 7 days | 10 of 10 | 2026-02-09 | 2026-02-16 | Overdue |
| DIVALPROEX 250MG DR TAB 250MG DR 57237004701 · Rx 35815 |
— | 3 / 1 days | 1 of 3 | 2026-01-15 | 2026-01-16 | Overdue |
| JTEST-TRAZODONE 50MG TAB 50MG 50111043303 · Rx 36212 |
— | 7 / 7 days | 3 of 3 | 2025-11-21 | 2025-11-28 | Overdue |
| ALPRAZOLAM 2MG ER TAB 2MG ER 00228308706 · Rx 35813 |
— | 30 / 30 days | 2 of 2 | 2025-08-06 | 2025-09-05 | Overdue |
| VYVANSE 30MG CAP 30MG 59417010310 · Rx 35811 |
— | 30 / 30 days | 0 of 0 | 2025-08-06 | 2025-09-05 | Completed |
| APAP/CODEINE 300-30MG TAB 300-30MG 00093015001 · Rx 35812 |
— | 10 / 1 days | 0 of 0 | 2025-08-06 | 2025-08-07 | Completed |
| PSB SYNTHETIC PRODUCT 00093015001 · Rx 35812 |
— | 10 / 1 days | 0 of 0 | 2025-08-06 | 2025-08-07 | Completed |
| YEZTUGO 300MG TAB 300MG 61958340101 · Rx 35742 |
— | 4 / 4 days | 1 of 1 | 2025-07-31 | 2025-08-04 | Overdue |
| YEZTUGO 463.5MG INJ 463.5MG 61958340201 · Rx 35743 |
— | 1.5 / 2 days | 1 of 1 | 2025-07-31 | 2025-08-02 | Overdue |
| ABILIFY MAINTENA 300MG INJ 300MG 59148001871 · Rx 33415 |
— | 1 / 28 days | 3 of 5 | 2025-02-07 | 2025-03-07 | Overdue |
| BUTRANS 10MCG/HR DIS 10MCG/HR 59011075104 · Rx 34786 |
— | 1 / 1 days | 3 of 4 | 2025-02-07 | 2025-02-08 | Overdue |
| MODERNA COVID BIVAL BSTR 0.5ML BA4/BA5 80777028299 · Rx 32679 |
— | 0.5 / 1 days | 0 of 0 | 2023-10-13 | 2023-10-14 | Completed |
| INGREZZA 40MG CAP 40MG 70370204001 · Rx 32314 |
— | 1 / 1 days | 1 of 2 | 2023-07-27 | 2023-07-28 | Overdue |
| FLUCONAZOLE 100MG TAB 100MG 00093720356 · Rx 32031 |
— | 1 / 1 days | 0 of 0 | 2023-04-19 | 2023-04-20 | Completed |
| FLUCONAZOLE 100MG TAB 100MG 00172541146 · Rx 32030 |
— | 1 / 1 days | 0 of 0 | 2023-04-19 | 2023-04-20 | Completed |
| PREVNAR 13 INJ 00005197105 · Rx 31749 |
— | 0.5 / 1 days | 0 of 0 | 2023-01-20 | 2023-01-21 | Completed |
| NALOXONE IM RESCUE KIT 2 DOSE 0.4MG/ML 67457029201 · Rx 31642 |
— | 1 / 1 days | 4 of 5 | 2023-01-18 | 2023-01-19 | Overdue |
| 340B-TRAZODONE 50MG TAB 50MG 50111043301 · Rx 31183 |
— | 28 / 28 days | 2 of 3 | 2022-10-11 | 2022-11-08 | Overdue |
| CABENUVA 600-900 SUS 600-900 49702024015 · Rx 31494 |
— | 6 / 6 days | 0 of 0 | 2022-09-12 | 2022-09-18 | Completed |
| SUBLOCADE 300/1.5 INJ 300/1.5 12496030001 · Rx 31507 |
— | 1.5 / 2 days | 0 of 0 | 2022-09-13 | 2022-09-15 | Completed |
| NAPROXEN 500MG TAB 500MG 00143134801 · Rx 31185 |
— | 56 / 28 days | 5 of 6 | 2022-07-25 | 2022-08-22 | Overdue |
| TRIAMCINOLONE 0.5% CREAM 0.5% 67877031815 · Rx 31184 |
— | 15 / 15 days | 6 of 6 | 2022-07-25 | 2022-08-09 | Overdue |
| SERTRALINE 100MG TAB 100MG 00378418805 · Rx 31181 |
— | 56 / 56 days | 3 of 3 | 2022-06-01 | 2022-07-27 | Overdue |
| RISPERDAL CONSTA 12.5MG INJ 12.5MG 50458030911 · Rx 31216 |
— | 1 / 14 days | 0 of 0 | 2022-07-07 | 2022-07-21 | Completed |
| MYRBETRIQ 50MG TAB 50MG 00469260230 · Rx 31182 |
XFer To RPH3 @ CVS PHARMACY # 05651 - 1602 EAST HIGHWAY 83, WESLACO, T | 28 / 28 days | 3 of 3 | 2022-06-01 | 2022-06-29 | Overdue |
| ATORVASTATIN 20MG TAB 20MG 00591377519 · Rx 31180 |
— | 28 / 28 days | 3 of 3 | 2022-06-01 | 2022-06-29 | Overdue |
| BUPROPION HCL 150MG XL TAB 150MG XL 00115681110 · Rx 31179 |
— | 28 / 28 days | 3 of 3 | 2022-06-01 | 2022-06-29 | Overdue |
| LAMOTRIGINE 250MG ER TAB 250MG ER 49884060411 · Rx 31178 |
— | 28 / 28 days | 3 of 3 | 2022-06-01 | 2022-06-29 | Overdue |
| OMEPRAZOLE 20MG CAP 20MG 60505006501 · Rx 31177 |
— | 30 / 28 days | 3 of 3 | 2022-06-01 | 2022-06-29 | Overdue |
| ALBUTEROL HFA AER HFA 66993001968 · Rx 31153 |
— | 18 / 15 days | 99 of 99 | 2022-05-10 | 2022-05-25 | Overdue |