Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| RELAY TEST PLAN | Primary | ||||
| ADVANCE/PCS 8 | Secondary | ||||
| HARDSHIP ASSISTANCE | Y | Secondary | |||
| PRIVATE | PR | Secondary | |||
| RELAY TEST PLAN COPAY | Secondary | ||||
| RELAY TEST CAPTURED RESP | 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 |
|---|---|---|---|---|---|---|
| WARFARIN 10MG TAB 10MG 00555083502 · Rx 34902 |
— | 28 / 28 days | 2 of 3 | 2025-08-01 | 2025-08-29 | Overdue |
| XYZAL 5MG TAB 5MG 00024580090 · Rx 35136 |
— | 7 / 7 days | 3 of 3 | 2025-03-24 | 2025-03-31 | Overdue |
| MULTIVIT/FL 1MG CHW 1MG 00093916601 · Rx 34534 |
— | 30 / 30 days | 3 of 3 | 2025-01-07 | 2025-02-06 | Overdue |
| XYZAL 5MG TAB 5MG 00024580090 · Rx 34607 |
— | 7 / 7 days | 3 of 3 | 2025-01-21 | 2025-01-28 | Overdue |
| FISH OIL 1000MG CAP 1000MG 00904404360 · Rx 34535 |
— | 7 / 7 days | 2 of 3 | 2025-01-21 | 2025-01-28 | Overdue |
| SAFETY SYRNG 25GX5/8" MIS 25GX5/8" 08290305554 · Rx 33901 |
— | 100 / 100 days | 3 of 3 | 2024-08-16 | 2024-11-24 | Overdue |
| CLOPIDOGREL 75MG TAB 75MG 47335089481 · Rx 33942 |
— | 1 / 30 days | 1 of 1 | 2024-08-23 | 2024-09-22 | Overdue |
| JTEST-TRAZODONE 50MG TAB 50MG 50111043303 · Rx 33411 |
— | 28 / 28 days | 1 of 3 | 2024-08-23 | 2024-09-20 | Overdue |
| LITHIUM CARB 300MG CAP 300MG 68462022101 · Rx 33410 |
— | 84 / 28 days | 2 of 3 | 2024-08-23 | 2024-09-20 | Overdue |
| METFORMIN 1000MG TAB 1000MG 68462016105 · Rx 33408 |
— | 56 / 28 days | 5 of 6 | 2024-08-23 | 2024-09-20 | Overdue |
| PIOGLITAZONE 15MG TAB 15MG 16729002010 · Rx 33844 |
— | 30 / 30 days | 2 of 3 | 2024-08-16 | 2024-09-15 | Overdue |
| SPIRIVA HANDIHLR CAP HANDIHLR 00597007541 · Rx 33846 |
— | 30 / 30 days | 0 of 0 | 2024-08-13 | 2024-09-12 | Completed |
| OMEPRAZOLE 20MG CAP 20MG 60505006501 · Rx 33845 |
— | 30 / 30 days | 0 of 0 | 2024-08-13 | 2024-09-12 | Completed |
| CETAPHIL DRY/SENS BAR DRY/SENS 00299392304 · Rx 33912 |
— | 1 / 10 days | 3 of 3 | 2024-08-16 | 2024-08-26 | Overdue |
| NORMAL SALIN 0.9% INJ 0.9% 08290093010 · Rx 33891 |
— | 10 / 10 days | 0 of 0 | 2024-08-16 | 2024-08-26 | Completed |
| WITCH HAZEL EXT 00395321316 · Rx 33945 |
— | 480 / 1 days | 0 of 0 | 2024-08-23 | 2024-08-24 | Completed |
| PLAVIX 75MG TAB 75MG 63653117103 · Rx 33941 |
— | 1 / 1 days | 0 of 0 | 2024-08-23 | 2024-08-24 | Completed |
| DULOXETINE 30MG CAP 30MG 60505299603 · Rx 33412 |
— | 28 / 28 days | 2 of 3 | 2024-07-25 | 2024-08-22 | Overdue |
| DIVALPROEX 125MG DR TAB 125MG DR 60505306501 · Rx 33409 |
— | 84 / 28 days | 2 of 3 | 2024-07-25 | 2024-08-22 | Overdue |
| TOPROL XL 50MG TAB 50MG 70347005002 · Rx 33851 |
— | 5 / 5 days | 0 of 0 | 2024-08-14 | 2024-08-19 | Completed |
| WARFARIN 10MG TAB 10MG 00555083502 · Rx 33519 |
— | 28 / 28 days | 3 of 3 | 2024-06-04 | 2024-07-02 | Overdue |
| AMLODIPINE 2.5MG TAB 2.5MG 69097083605 · Rx 33414 |
— | 30 / 30 days | 6 of 6 | 2024-05-03 | 2024-06-02 | Overdue |
| ESOMEPRAZOLE 20MG DR CAP 20MG DR 00093645098 · Rx 33413 |
— | 28 / 28 days | 6 of 6 | 2024-05-03 | 2024-05-31 | Overdue |
| SPRAVATO 56MG DOS SOL 56MG DOS 50458002802 · Rx 33382 |
— | 2 / 2 days | 3 of 3 | 2024-04-29 | 2024-05-01 | Overdue |
| LISINOPRIL 10MG TAB 10MG 68180098003 · Rx 33209 |
— | 30 / 30 days | 0 of 0 | 2024-03-12 | 2024-04-11 | Completed |
| TRIAM/HCTZ 37.5-25 CAP 37.5-25 00378253701 · Rx 33224 |
— | 28 / 28 days | 3 of 3 | 2024-03-13 | 2024-04-10 | Overdue |
| LUPRON 2 WEEK INJ 2 WEEK 00300361228 · Rx 33034 |
— | 1 / 14 days | 3 of 3 | 2024-02-07 | 2024-02-21 | Overdue |
| SPRAVATO 56MG DOS SOL 56MG DOS 50458002802 · Rx 32948 |
— | 40 / 10 days | 2 of 2 | 2024-01-17 | 2024-01-27 | Overdue |
| ENBREL 50MG/ML INJ 50MG/ML 58406043504 · Rx 32946 |
— | 3.92 / 1 days | 2 of 3 | 2024-01-18 | 2024-01-19 | Overdue |
| SKYRIZI 150DOSE INJ 150DOSE 00074204271 · Rx 32947 |
— | 1 / 1 days | 0 of 0 | 2024-01-17 | 2024-01-18 | Completed |