Patient record
| Payer | Plan | Member ID | Group ID | Relationship | Primary |
|---|---|---|---|---|---|
| RELAY TEST PLAN | TST123 | GRP456789 | Primary | ||
| PRIVATE | PR | Secondary | |||
| RELAY TEST PLAN COPAY | TS20001 | GRP98ABC | Secondary | ||
| RELAY TEST PLAN TERTIARY | TS3012001 | GRP22ABCD | 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 |
|---|---|---|---|---|---|---|
| FARXIGA 10MG TAB 10MG 00310621030 · Rx 37124 |
— | 5 / 5 days | 0 of 0 | 2026-08-13 | 2026-08-18 | Completed |
| FARXIGA 10MG TAB 10MG 00310621030 · Rx 37110 |
— | 5 / 5 days | 0 of 0 | 2026-08-12 | 2026-08-17 | Completed |
| FARXIGA 10MG TAB 10MG 00310621030 · Rx 37109 |
— | 5 / 5 days | 0 of 0 | 2026-08-07 | 2026-08-12 | Completed |
| FARXIGA 10MG TAB 10MG 00310621030 · Rx 37108 |
— | 3 / 3 days | 0 of 0 | 2026-08-07 | 2026-08-10 | Completed |
| HYDROXYZINE PAMOATE 25MG CAP 25MG 00185067405 · Rx 36655 |
— | 21 / 21 days | 3 of 3 | 2026-04-07 | 2026-04-28 | Overdue |
| ATENOLOL 100MG TAB 100MG 68382002401 · Rx 36657 |
— | 10 / 10 days | 5 of 5 | 2026-04-07 | 2026-04-17 | Overdue |
| BENZTROPINE 1MG TAB 1MG 76385010410 · Rx 36654 |
— | 10 / 10 days | 5 of 5 | 2026-04-07 | 2026-04-17 | Overdue |
| XYZAL 5MG TAB 5MG 00024580090 · Rx 36656 |
— | 7 / 7 days | 6 of 6 | 2026-04-07 | 2026-04-14 | Overdue |
| FLUOXETINE 20MG CAP 20MG 55111014810 · Rx 36653 |
— | 7 / 7 days | 5 of 5 | 2026-04-07 | 2026-04-14 | Overdue |