Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| PRIVATE | PR | 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 |
|---|---|---|---|---|---|---|
| DIVALPROEX ER 250MG TAB 250MG ER 65862059401 · Rx 36640 |
— | 84 / 28 days | 1 of 1 | 2026-04-02 | 2026-04-30 | Overdue |
| MAG OXIDE 400MG TAB 400MG 64980033912 · Rx 36639 |
— | 56 / 28 days | 3 of 3 | 2026-04-02 | 2026-04-30 | Overdue |
| ROSUVASTATIN 40MG TAB 40MG 27808015803 · Rx 36638 |
— | 28 / 28 days | 11 of 11 | 2026-04-02 | 2026-04-30 | Overdue |
| DONEPEZIL 5MG TAB 5MG 43547027509 · Rx 36637 |
— | 28 / 28 days | 11 of 11 | 2026-04-02 | 2026-04-30 | Overdue |
| OLANZAPINE 10MG TAB 10MG 43598016630 · Rx 36636 |
— | 28 / 28 days | 11 of 11 | 2026-04-02 | 2026-04-30 | Overdue |
| GLIPIZIDE ER 10MG TAB 10MG 16714089601 · Rx 36635 |
— | 28 / 28 days | 9 of 9 | 2026-04-02 | 2026-04-30 | Overdue |
| METFORMIN 500MG TAB 500MG 42385094701 · Rx 36634 |
— | 56 / 28 days | 9 of 9 | 2026-04-02 | 2026-04-30 | Overdue |
| FAMOTIDINE 20MG TAB 20MG 31722001701 · Rx 36633 |
— | 28 / 28 days | 9 of 9 | 2026-04-02 | 2026-04-30 | Overdue |
| ALLOPURINOL 100MG TAB 100MG 16714057602 · Rx 36632 |
— | 28 / 28 days | 9 of 9 | 2026-04-02 | 2026-04-30 | Overdue |
| ATENOLOL 50MG TAB 50MG 29300041101 · Rx 36631 |
— | 28 / 28 days | 9 of 9 | 2026-04-02 | 2026-04-30 | Overdue |
| LOSARTAN POT 25MG TAB 25MG 31722070090 · Rx 36630 |
— | 28 / 28 days | 9 of 9 | 2026-04-02 | 2026-04-30 | Overdue |