Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| HARDSHIP ASSISTANCE | 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 |
|---|---|---|---|---|---|---|
| VERAPAMIL 100MG ER CAP-APS 100MG ER 00378620101 · Rx 34532 |
— | 7 / 7 days | 2 of 3 | 2025-11-17 | 2025-11-24 | Overdue |
| ATORVASTATIN 20MG TAB 20MG 60505257908 · Rx 33831 |
— | 30 / 30 days | 3 of 3 | 2024-10-18 | 2024-11-17 | Overdue |
| DIPHENHYDRAM 25MG CAP 25MG 00182049210 · Rx 34176 |
— | 15 / 8 days | 3 of 3 | 2024-10-18 | 2024-10-26 | Overdue |
| HALOPERIDOL 5MG TAB 5MG 00378032710 · Rx 34175 |
— | 15 / 8 days | 3 of 3 | 2024-10-18 | 2024-10-26 | Overdue |
| AZITHROMYCIN 600MG TAB 600MG 50111078910 · Rx 34174 |
— | 3 / 3 days | 3 of 3 | 2024-10-18 | 2024-10-21 | Overdue |
| AMIODARONE 200MG TAB 200MG 00781120360 · Rx 33832 |
— | 30 / 30 days | 3 of 3 | 2024-08-09 | 2024-09-08 | Overdue |
| LISINOPRIL 20MG TAB 20MG 00603421221 · Rx 33830 |
— | 30 / 30 days | 3 of 3 | 2024-08-09 | 2024-09-08 | Overdue |
| GABAPENTIN 300MG CAP 300MG 00228266650 · Rx 33829 |
— | 90 / 30 days | 3 of 3 | 2024-08-09 | 2024-09-08 | Overdue |
| CABENUVA 400-600 SUS 400-600 49702025315 · Rx 33833 |
— | 4 / 1 days | 0 of 0 | 2024-08-09 | 2024-08-10 | Completed |