Provider Alert

May 6, 2016

Antipsychotic Medications for Foster Care and Adoption Support Clients

This alert (previously sent on April 29, 2016) is being reissued with a revised effective date.
The new effective date is July 1, 2016.

What is changing?

Effective for dates of service on and after July 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 July 1, 2016.

Please do not reply directly to this message. If you have feedback or questions, please visit the HCA website for contact information.

About Washington State Health Care Authority
HCA oversees the state’s top two health care purchasers — Washington Apple Health (Medicaid) and the Public Employee Benefits Board Program. We work with partners to help ensure Washingtonians have access to better health and better care at a lower cost. For more information, visit www.hca.wa.gov.