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Related article: (also checks for oxycontin limits exceeded)) If the prescription originated by telephone for a schedule II drug AND It is not an emergency service level AND It is not a paper claim B B B B 75 Prior Authorization Required 4149 B If the Daily Dose (derived by taking Claim Submitted Quantity / Claim Days Supply) greater than Custom Plan Maintenance Claim Dose AND The Custom Plan Maintenance Indicator equals �Pay� AND The Prior authorization indicator is not equal to (�Prior Authorized� or �Covered�). B B B B 75 Prior Authorization Required 4150 B If the Custom Plan Maximum Daily Dose Units is not equal to 0 AND The Daily Dose (derived by taking Claim Submitted Quantity / Claim Days Supply) greater than Custom Plan Maximum Daily Dose AND Claim dose indicator equals �pay� AND The Prior authorization indicator is not equal to (�Prior Authorized� or �Covered�). D D D D 75 Prior Authorization Required 4151 B If the Custom Plan Minimum Daily Dose Clonazepam 5mg Vs Valium Units is not equal to 0 AND The Daily Dose (derived by taking Claim Submitted Quantity / Claim Days Supply) is less than the Custom Plan Minimum Daily Dose AND The Prior authorization indicator is not equal to (�Prior Authorized� or �Covered�). D D D D 75 Prior Authorization Required 4152 B The Claim Participant Age is not less than the Custom Plan Drug Maximum Age AND The Prior authorization indicator is not equal to (�Prior Authorized� or �Covered�) AND The Custom Plan Age Edit Status equals �PA Required� AND The Claim�s Prior Authorization Type Code not = �PA Override� (�8�). D D D D
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