Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| 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 |
|---|---|---|---|---|---|---|
| INVEGA 1.5MG TAB 1.5MG 50458055401 · Rx 34172 |
— | 15 / 15 days | 2 of 5 | 2025-06-06 | 2025-06-21 | Overdue |
| GLYBURIDE 5MG TAB 5MG 51079087320 · Rx 35353 |
— | 7 / 7 days | 3 of 3 | 2025-06-06 | 2025-06-13 | Overdue |
| METFORMIN 1000MG ER TAB 1000MG 65162017750 · Rx 35352 |
— | 7 / 7 days | 3 of 3 | 2025-06-06 | 2025-06-13 | Overdue |
| BUTRANS 10MCG/HR DIS 10MCG/HR 59011075104 · Rx 34774 |
— | 1 / 1 days | 2 of 2 | 2025-02-07 | 2025-02-08 | Overdue |
| VITAMIN D 50000UNT CAP 50000UNT 64980015701 · Rx 33093 |
— | 1 / 1 days | 3 of 5 | 2024-10-28 | 2024-10-29 | Overdue |
| LISINOPRIL 10MG TAB 10MG 68180051401 · Rx 33092 |
— | 14 / 14 days | 3 of 3 | 2024-02-19 | 2024-03-04 | Overdue |
| SPRAVATO 56MG DOS SOL 56MG DOS 50458002802 · Rx 32690 |
— | 1 / 1 days | 1 of 3 | 2023-10-18 | 2023-10-19 | Overdue |
| INGREZZA 80MG CAP 80MG 70370108001 · Rx 32299 |
— | 1 / 1 days | 1 of 5 | 2023-07-28 | 2023-07-29 | Overdue |