Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| MED D HORIZON BC/BS | Primary | ||||
| PRIVATE | PR | Secondary | |||
| RELAY TEST PLAN COPAY | 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 |
|---|---|---|---|---|---|---|
| IDP-SERTRALINE 100MG TAB 100MG 69097083512 · Rx 36465 |
— | 7 / 7 days | 10 of 10 | 2026-02-09 | 2026-02-16 | Overdue |
| LISINOP-HCTZ 10-12.5 TAB 10-12.5 00185710001 · Rx 35242 |
— | 7 / 7 days | 3 of 3 | 2025-11-17 | 2025-11-24 | Overdue |
| GABAPENTIN 100MG CAP-APS 100MG 67877022201 · Rx 35200 |
— | 30 / 30 days | 0 of 0 | 2025-05-05 | 2025-06-04 | Completed |
| DIVALPROEX 250MG DR TAB 250MG DR 57237004705 · Rx 35199 |
— | 90 / 30 days | 3 of 3 | 2025-05-05 | 2025-06-04 | Overdue |
| CALCIUM 600MG TAB 00536342608 · Rx 35198 |
— | 60 / 30 days | 3 of 3 | 2025-05-05 | 2025-06-04 | Overdue |
| VIMPAT 50MG TAB 50MG 00131247735 · Rx 35197 |
— | 30 / 30 days | 1 of 1 | 2025-05-05 | 2025-06-04 | Overdue |
| ALPRAZOLAM 2MG ER TAB 2MG ER 65162081206 · Rx 35196 |
— | 30 / 30 days | 2 of 2 | 2025-05-05 | 2025-06-04 | Overdue |
| VYVANSE 30MG CAP 30MG 59417010310 · Rx 35194 |
— | 30 / 30 days | 0 of 0 | 2025-05-05 | 2025-06-04 | Completed |
| APAP/CODEINE 300-30MG TAB 300-30MG 00093015001 · Rx 35195 |
— | 10 / 1 days | 0 of 0 | 2025-05-05 | 2025-05-06 | Completed |
| PSB SYNTHETIC PRODUCT 00093015001 · Rx 35195 |
— | 10 / 1 days | 0 of 0 | 2025-05-05 | 2025-05-06 | Completed |
| DIVALPROEX 125MG CAP 125MG 68084031301 · Rx 32793 |
123 testing | 120 / 30 days | 3 of 3 | 2023-12-01 | 2023-12-31 | Overdue |
| SPRAVATO 84MG DOS SOL 84MG DOS 50458002803 · Rx 32718 |
— | 1 / 1 days | 3 of 3 | 2023-10-20 | 2023-10-21 | Overdue |
| AUSTEDO 9MG TAB 9MG 68546017160 · Rx 32316 |
— | 1 / 1 days | 3 of 3 | 2023-07-27 | 2023-07-28 | Overdue |
| PROAIR RESPI AER 59310058020 · Rx 32161 |
— | 1 / 17 days | 0 of 0 | 2023-05-24 | 2023-06-10 | Completed |
| AMPHETAMINE SALT COMBO*ER*30MG 30MG ER 00228306111 · Rx 32162 |
test | 30 / 10 days | 0 of 0 | 2023-05-24 | 2023-06-03 | Completed |
| SHINGRIX 50/0.5ML INJ 50/0.5ML 58160082311 · Rx 32195 |
— | 0.5 / 1 days | 0 of 0 | 2023-05-31 | 2023-06-01 | Completed |
| MODERNA COVID BIVAL BSTR 0.5ML BA4/BA5 80777028299 · Rx 32194 |
— | 0.05 / 1 days | 0 of 0 | 2023-05-31 | 2023-06-01 | Completed |
| PFIZER COVID BIVAL BSTR BA4/BA5 59267030402 · Rx 32193 |
— | 0.3 / 1 days | 0 of 0 | 2023-05-31 | 2023-06-01 | Completed |
| SHINGRIX 50/0.5ML INJ 50/0.5ML 58160082311 · Rx 32189 |
— | 0.5 / 1 days | 0 of 0 | 2023-05-31 | 2023-06-01 | Completed |
| MODERNA COVID BIVAL BSTR 0.5ML BA4/BA5 80777028299 · Rx 32185 |
— | 0.05 / 1 days | 0 of 0 | 2023-05-31 | 2023-06-01 | Completed |
| PFIZER COVID BIVAL BSTR BA4/BA5 59267030402 · Rx 32184 |
— | 0.3 / 1 days | 0 of 0 | 2023-05-31 | 2023-06-01 | Completed |