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Antipsychotic
Medications for Foster Care and Adoption Support Clients
What
is changing?
Effective for dates of service on and after June 1,
2016, all new prescriptions for antipsychotic medications prescribed to
Washington Apple Health clients age 17 and younger in the Foster Care Medical and
Adoption Support Medical programs will require authorization and review through
the agency’s contracted Second Opinion Network.
This requirement applies to clients whether enrolled in fee-for-service or
Coordinated Care.
How
will existing or previously reviewed prescriptions be handled?
Existing prescriptions will not require
authorization for the life of the prescription (until one year from the date
written, or the maximum number of refills has been reached). Prescriptions previously reviewed through the
Second Opinion Network will not require another review unless changes are made
in the directions for use.
Antipsychotics prescribed for Foster Care Medical
and Adoption Support Medical clients age 17 and younger will require
authorization and review at the time the prescription is renewed or changed. Existing antipsychotic prescriptions will be
approved for payment as written until the Second Opinion review process is
completed.
What
do pharmacies need to do?
When receiving claim rejections for antipsychotic
medications, contact the patient’s health carrier (either Apple Health
fee-for-service or Coordinated Care) or request authorization.
What
do prescribers need to do?
Second Opinion reviews are initiated by the Health
Care Authority (the agency) or its contracted managed care organization when a
pharmacy requests authorization.
Prescribers do not need to contact the agency or the Second Opinion Network
directly to initiate the authorization request or review process. Prescribers will receive a request for
records and chart notes from the agency.
After submitting requested chart notes, the prescriber will be contacted
by the agency’s contracted Second Opinion Network (Seattle Children’s) to
schedule a peer-to-peer review with an agency-designated pediatric mental
health specialist. Antipsychotic
prescriptions are approved or denied based on the treatment recommendations of
the Second Opinion Network.
The agency will update the Prescription Drug Provider Guide by June 1,
2016.
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