Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| PRIVATE | PR | Secondary | |||
| RELAY TEST PLAN COPAY | TEST12 | Secondary | |||
| RELAY TEST PLAN TERTIARY | 1111TEST | 2222TEST | 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 |
|---|---|---|---|---|---|---|
| ALPRAZOLAM 2MG ER TAB 2MG ER 65162081206 · Rx 36658 |
— | 1 / 1 days | 5 of 5 | 2026-04-07 | 2026-04-08 | Overdue |
| BENZTROPINE 0.5MG TAB 0.5MG 76385010301 · Rx 34739 |
— | 100 / 100 days | 0 of 0 | 2025-11-16 | 2026-02-24 | Completed |
| TRAZODONE 100MG TAB 100MG 50111043403 · Rx 34737 |
— | 100 / 100 days | 3 of 3 | 2025-11-16 | 2026-02-24 | Overdue |
| JANUVIA 100MG TAB 100MG 00006027702 · Rx 36341 |
— | 1 / 1 days | 99 of 99 | 2025-12-24 | 2025-12-25 | Overdue |
| WARFARIN 10MG TAB 10MG 68382005901 · Rx 35488 |
— | 7 / 7 days | 3 of 3 | 2025-06-25 | 2025-07-02 | Overdue |
| AFLURIA QUAD 2020-2021 VIAL 2020-21 33332042010 · Rx 35047 |
— | 0.5 / 1 days | 0 of 0 | 2025-03-11 | 2025-03-12 | Completed |
| TETRAHYDROZ POW 51927179600 · Rx 34889 |
— | 50 / 13 days | 4 of 4 | 2025-02-25 | 2025-03-10 | Overdue |
| IMMUNE GLOBU HUMAN INJ HUMAN 52769057622 · Rx 34958 |
— | 2 / 2 days | 0 of 0 | 2025-03-06 | 2025-03-08 | Completed |
| DIP/TET PED 6.7-5LF INJ 6.7-5LF 49281027810 · Rx 34973 |
— | 0.5 / 1 days | 0 of 0 | 2025-03-06 | 2025-03-07 | Completed |
| MODERNA COVID BIVAL BSTR 0.5ML BA4/BA5 80777028299 · Rx 34960 |
— | 0.5 / 1 days | 0 of 0 | 2025-03-06 | 2025-03-07 | Completed |
| PNEUMOVAX 23 25MCG/.5 INJ 25/0.5 00006494300 · Rx 34959 |
— | 0.5 / 1 days | 0 of 0 | 2025-03-06 | 2025-03-07 | Completed |
| DIP/TET PED 6.7-5LF INJ 6.7-5LF 49281027810 · Rx 34957 |
— | 1 / 1 days | 0 of 0 | 2025-03-06 | 2025-03-07 | Completed |
| SELEGILINE 5MG TAB 5MG 60505343803 · Rx 34624 |
— | 7 / 7 days | 3 of 3 | 2025-01-22 | 2025-01-29 | Overdue |
| VYVANSE 20MG CAP 20MG 59417010210 · Rx 34495 |
— | 30 / 30 days | 3 of 3 | 2024-12-27 | 2025-01-26 | Overdue |
| AMPHETAMINE 10MG TAB 340B 10MG 00555097202 · Rx 34494 |
— | 30 / 30 days | 3 of 3 | 2024-12-27 | 2025-01-26 | Overdue |
| PILOCARPINE 5MG TAB 5MG 00115592201 · Rx 34523 |
— | 7 / 7 days | 3 of 3 | 2025-01-07 | 2025-01-14 | Overdue |
| VYVANSE 70MG CAP 70MG 59417010710 · Rx 34496 |
— | 15 / 1 days | 3 of 3 | 2024-12-27 | 2024-12-28 | Overdue |
| METOPROLOL 25MG ER TAB 25MG ER 49884040401 · Rx 33114 |
— | 30 / 30 days | 4 of 5 | 2024-10-28 | 2024-11-27 | Overdue |
| HYDROXYZINE HCL 10MG TAB 10MG 23155050001 · Rx 33112 |
— | 30 / 30 days | 2 of 3 | 2024-10-28 | 2024-11-27 | Overdue |
| CITALOPRAM 20MG TAB 20MG 00378623201 · Rx 32736 |
— | 30 / 30 days | 2 of 3 | 2024-05-24 | 2024-06-23 | Overdue |
| 49230064021 49230064021 · Rx 33113 |
— | 60 / 30 days | 6 of 6 | 2024-02-26 | 2024-03-27 | Overdue |
| PFIZER COVID BIVAL BSTR BA4/BA5 59267030402 · Rx 33052 |
— | 0.3 / 1 days | 0 of 0 | 2024-02-08 | 2024-02-09 | Completed |
| SPRAVATO 56MG DOS SOL 56MG DOS 50458002802 · Rx 32915 |
— | 2 / 1 days | 2 of 2 | 2024-01-11 | 2024-01-12 | Overdue |
| SPRAVATO 84MG DOS SOL 84MG DOS 50458002803 · Rx 32706 |
— | 3 / 1 days | 3 of 3 | 2023-10-19 | 2023-10-20 | Overdue |