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By Lorazepam Online

(2011-11-24 03:16:41)
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Related article: B Client Specific By Lorazepam Online (IN) Non-PDL Drug - Prior Authorization Required (TCP Program) B B B B 75 Prior Authorization Required 4140 B If the (Custom Plan Max Units Accum is not equal to �N� (None) OR The Custom Plan Max Units is not equal to Work Default Max Units (99999.999)) AND The Custom Plan Max Units Accum equals �C� (Acute Dose Only) AND The Custom Plan Maintenance Claim Dose less than Work Default Dose (9999.999) AND The Daily Dose (derived by taking Claim Submitted Quantity / Claim Days Supply) greater than Custom Plan Maintenance Claim Dose AND The Claim Submitted Quantity is greater than Custom Plan Max Units AND The Custom Plan Max Units Status equals �P� (PA Required) AND The prior authorization indicator is not equal to (�Prior Authorized� or �Covered�). D D D D 75 Prior Authorization Required 4141 B If the Custom Plan Max Units Accum equals �A� (All Doses) AND The Claim Submitted Quantity is greater than Custom Plan Max Units AND The Custom Plan Max Units Status equals �P� (PA Required) AND The Prior authorization indicator is not equal to (�Prior Authorized� or �Covered�). D D D D 75 Prior Authorization Required 4142 B If the Custom Plan Max Number of Refills is not equal to �Unlimited� (999) AND The Plan Benefit Limit Override PA equals �I� (Override Initial RX) AND The Claim Refill Indicator greater 0 AND The Custom Plan Max Number of Refills less than (<) The Claim Refill Indicator AND The Prior authorization indicator is not equal to (�Prior Authorized� or �Covered�). B B B B 75 Prior Authorization Required 4143 B The Plan Benefit Limits indicate �Not Covered� AND
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