Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| EXPRESS SCRIPTS INSURANCE | Secondary | ||||
| PRIVATE | PR | Secondary | |||
| RELAY TEST PLAN COPAY | 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 |
|---|---|---|---|---|---|---|
| AMOXICILLIN 125MG CHW 125MG 00093226701 · Rx 35360 |
— | 50 / 25 days | 2 of 3 | 2025-11-26 | 2025-12-21 | Overdue |
| IPRATROPIUM 0.02%INH SOL 0.02%INH 00591379883 · Rx 35362 |
— | 90 / 30 days | 3 of 3 | 2025-11-17 | 2025-12-17 | Overdue |
| TRAZODONE 150MG TAB 150MG 60505265501 · Rx 35359 |
— | 7 / 7 days | 2 of 3 | 2025-11-26 | 2025-12-03 | Overdue |
| VENTOLIN HFA AER 00173068224 · Rx 35361 |
— | 8 / 3 days | 2 of 3 | 2025-11-26 | 2025-11-29 | Overdue |
| SERTRALINE 100MG TAB 100MG 68180035302 · Rx 34782 |
— | 100 / 100 days | 2 of 3 | 2025-06-06 | 2025-09-14 | Overdue |
| BUPRENORPHIN 8MG SUB 8MG 00054017713 · Rx 34781 |
— | 1 / 1 days | 2 of 3 | 2025-02-07 | 2025-02-08 | Overdue |
| SPRAVATO 56MG DOS SOL 56MG DOS 50458002802 · Rx 32941 |
— | 22 / 11 days | 1 of 2 | 2024-01-17 | 2024-01-28 | Overdue |
| NASAL 0.05% SPR 0.05% 24385030410 · Rx 32686 |
— | 30 / 5 days | 5 of 5 | 2023-10-01 | 2023-10-06 | Overdue |
| JTEST-FLUOXETINE 20MG CAP 20MG 65862019301 · Rx 32685 |
— | 5 / 5 days | 5 of 5 | 2023-10-01 | 2023-10-06 | Overdue |