Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| CAREMARK | 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 |
|---|---|---|---|---|---|---|
| MULTIVITAMINS MULT VIT 57896050401 · Rx 34730 |
— | 100 / 100 days | 3 of 3 | 2025-02-05 | 2025-05-16 | Overdue |
| VITAMIN E 1000IU CAP 1000UNIT 00904027760 · Rx 34510 |
— | 7 / 7 days | 3 of 3 | 2025-01-06 | 2025-01-13 | Overdue |
| LANSOPRAZOLE 15MG CAP 15MG DR 55111039830 · Rx 32378 |
— | 14 / 14 days | 3 of 5 | 2024-05-31 | 2024-06-14 | Overdue |
| SUBLOCADE 100/0.5 INJ 100/0.5 12496010005 · Rx 33392 |
— | 0.5 / 1 days | 2 of 2 | 2024-04-30 | 2024-05-01 | Overdue |
| ABILIFY MAINTENA DCS 300MG INJ 300MG 59148004580 · Rx 33104 |
— | 1 / 28 days | 0 of 0 | 2024-02-22 | 2024-03-21 | Completed |
| VYVANSE 10MG CAP 10MG 59417010110 · Rx 32839 |
— | 30 / 30 days | 1 of 1 | 2023-12-07 | 2024-01-06 | Overdue |
| FLUOXETINE 40MG CAP 40MG 63304063201 · Rx 32838 |
— | 30 / 30 days | 0 of 0 | 2023-12-07 | 2024-01-06 | Completed |
| CLONAZEPAM 0.125MG TAB 0.125MG 00555009496 · Rx 32837 |
— | 30 / 30 days | 3 of 3 | 2023-12-07 | 2024-01-06 | Overdue |
| ENBREL 50MG/ML INJ 50MG/ML 58406043504 · Rx 32601 |
— | 3.92 / 28 days | 0 of 0 | 2023-10-04 | 2023-11-01 | Completed |
| SPRAVATO 56MG DOS SOL 56MG DOS 50458002802 · Rx 32714 |
— | 1 / 1 days | 3 of 3 | 2023-10-20 | 2023-10-21 | Overdue |
| CAL GEST CW 500MG 150 500MG 00536100715 · Rx 32545 |
— | 90 / 30 days | 3 of 3 | 2023-09-13 | 2023-10-13 | Overdue |
| WIXELA INHUB 100/50 AER 100/50 00378932032 · Rx 32540 |
— | 60 / 30 days | 0 of 0 | 2023-09-13 | 2023-10-13 | Completed |
| CITALOPRAM 10MG TAB 10MG 65862000505 · Rx 32520 |
— | 30 / 30 days | 5 of 5 | 2023-09-08 | 2023-10-08 | Overdue |
| NARCAN 4MG/0.1ML SPR (2 DOSES) 69547035302 · Rx 32581 |
— | 2 / 1 days | 0 of 0 | 2023-09-27 | 2023-09-28 | Completed |
| LITHIUM CARB 300MG CAP 300MG 00904613661 · Rx 32306 |
— | 84 / 28 days | 4 of 5 | 2023-08-01 | 2023-08-29 | Overdue |
| ARIPIPRAZOLE 15MG TAB 15MG 31722082830 · Rx 32303 |
— | 28 / 28 days | 2 of 3 | 2023-08-01 | 2023-08-29 | Overdue |
| Z-ATORVASTATIN 10MG TAB 10MG 55111012190 · Rx 32305 |
— | 21 / 21 days | 1 of 2 | 2023-08-01 | 2023-08-22 | Overdue |
| DIVALPROEX 125MG CAP 125MG 68084031301 · Rx 32135 |
— | 56 / 28 days | 3 of 3 | 2023-07-14 | 2023-08-11 | Overdue |
| OMEPRAZOLE 20MG CAP 20MG 00378615010 · Rx 32304 |
— | 7 / 7 days | 5 of 6 | 2023-08-01 | 2023-08-08 | Overdue |