Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| RELAY TEST PLAN | Primary | ||||
| CAREMARK | Secondary | ||||
| PRIVATE | PR | Secondary | |||
| RELAY TEST PLAN COPAY | Secondary | ||||
| YESSICA'S TEST OPEN ITEM | 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 |
|---|---|---|---|---|---|---|
| TRAZODONE 150MG TAB 150MG 50111044102 · Rx 37103 |
— | 10 / 10 days | 1 of 1 | 2026-08-04 | 2026-08-14 | Overdue |
| DIGITEK 0.125MG TAB 0.125MG 62794014501 · Rx 37055 |
— | 10 / 10 days | 5 of 5 | 2026-07-20 | 2026-07-30 | Overdue |
| ISOSORB MONO 30MG ER TAB 30MG ER 59930309401 · Rx 36160 |
— | 7 / 14 days | 3 of 3 | 2025-11-18 | 2025-12-02 | Overdue |
| SERTRALINE 25MG TAB 25MG 00378418693 · Rx 36104 |
— | 7 / 7 days | 5 of 5 | 2025-11-11 | 2025-11-18 | Overdue |
| SOMA 250MG TAB 250MG 00037225010 · Rx 35887 |
— | 20 / 5 days | 1 of 1 | 2025-09-10 | 2025-09-15 | Overdue |
| WARFARIN 10MG TAB 10MG 68382005901 · Rx 35772 |
— | 10 / 10 days | 0 of 0 | 2025-08-04 | 2025-08-14 | Completed |
| AMPHETAMINE SALT 30MG *ER* CAP 30MG ER 66993059902 · Rx 35773 |
— | 5 / 5 days | 0 of 0 | 2025-08-04 | 2025-08-09 | Completed |
| WARFARIN 10MG TAB 10MG 68382005901 · Rx 35547 |
— | 10 / 10 days | 0 of 0 | 2025-07-03 | 2025-07-13 | Completed |
| ADDERALL XR 30MG CAP 340B 30MG 54092039101 · Rx 35464 |
— | 5 / 5 days | 0 of 0 | 2025-06-24 | 2025-06-29 | Completed |
| MODERNA COVID BIVAL BSTR 0.5ML BA4/BA5 80777028299 · Rx 34976 |
— | 0.5 / 1 days | 0 of 0 | 2025-03-06 | 2025-03-07 | Completed |
| BROMOCRIPTIN 2.5MG TAB 2.5MG 66685590500 · Rx 34656 |
— | 7 / 7 days | 3 of 3 | 2025-02-07 | 2025-02-14 | Overdue |
| BUPRENORPHIN POW 63275988401 · Rx 34784 |
— | 1 / 1 days | 2 of 3 | 2025-02-07 | 2025-02-08 | Overdue |
| UCARE INSULIN SYR 0.3/29G 1/2" 0.3/29G 08222092397 · Rx 34552 |
— | 100 / 25 days | 3 of 3 | 2025-01-09 | 2025-02-03 | Overdue |
| FLONASE 0.05% SPR 0.05% 00173045301 · Rx 34500 |
— | 16 / 30 days | 3 of 3 | 2024-12-30 | 2025-01-29 | Overdue |
| AMOXICILLIN/POT CLAV 875/125MG 875-125 66685100100 · Rx 34512 |
— | 10 / 5 days | 3 of 3 | 2025-01-06 | 2025-01-11 | Overdue |
| GUANFACINE 3MG **ER** TAB 3MG ER 00781545601 · Rx 34386 |
— | 7 / 7 days | 2 of 3 | 2025-01-03 | 2025-01-10 | Overdue |
| CITALOPRAM 20MG TAB 20MG 65862000605 · Rx 34481 |
— | 30 / 15 days | 10 of 10 | 2024-12-23 | 2025-01-07 | Overdue |
| ADVAIR DISKU 100/50 MIS 100/50 00173069504 · Rx 34385 |
— | 14 / 14 days | 0 of 0 | 2024-11-19 | 2024-12-03 | Completed |
| VENTOLIN HFA AER 00173068221 · Rx 34398 |
— | 8 / 8 days | 7 of 7 | 2024-11-20 | 2024-11-28 | Overdue |
| ESOMEPRA MAG 40MG DR CAP 40MG DR 13668015530 · Rx 34384 |
— | 7 / 7 days | 3 of 3 | 2024-11-19 | 2024-11-26 | Overdue |
| VANCOCIN HCL 125MG CAP 125MG 66593312502 · Rx 34383 |
— | 5 / 5 days | 3 of 3 | 2024-11-19 | 2024-11-24 | Overdue |
| ALLOPURINOL 100MG TAB 100MG 00603211521 · Rx 34317 |
— | 7 / 7 days | 3 of 3 | 2024-11-08 | 2024-11-15 | Overdue |
| HALOPERIDOL 5MG TAB 5MG 00378032710 · Rx 34215 |
— | 5 / 5 days | 3 of 3 | 2024-10-28 | 2024-11-02 | Overdue |
| CHLORHEX GLU 0.12% SOL 0.12% 00093001416 · Rx 34017 |
— | 473 / 1 days | 4 of 5 | 2024-10-28 | 2024-10-29 | Overdue |
| SPRAVATO 84MG DOS SOL 84MG DOS 50458002803 · Rx 34016 |
— | 3 / 1 days | 1 of 3 | 2024-10-28 | 2024-10-29 | Overdue |