Antipsychotic Medications for Foster Care and Adoption Support Clients

HCA Apple Health

PROVIDER ALERT

This alert is an update to a Provider Alert issued on May 6, 2016. The update is necessary because the Health Care Authority (the agency) has changed “How will existing or previously reviewed prescriptions be handled.”

Antipsychotic Medications for Foster Care and Adoption Support Clients

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 enrolled in either fee-for-service or Coordinated Care.

How will existing or previously reviewed prescriptions be handled?

Existing antipsychotic prescriptions will not require authorization until the following calendar month after the client’s birthday.  For example, if a client’s birthday is in November, an ongoing prescription will not require authorization until the first fill in December.  Clients with birthdays in June will start the authorization and review process in July.  Any changes to the current drug, drug strength, or dosage prescribed will require authorization at the time of the change, regardless of the client’s date of birth.

Existing antipsychotic prescriptions will be approved for continuation and payment as written until the Second Opinion review process is completed.

Prescriptions previously reviewed through the Second Opinion Network will not require another review unless changes are made in the directions for use. 

What do pharmacies need to do?

When a claim for antipsychotic medications is rejected, contact the patient’s health carrier (either Apple Health Fee-for-Service or Coordinated Care) to request authorization.

What do prescribers need to do?

Prescribers do not need to contact the agency or the Second Opinion Network directly to initiate the authorization request or review process. Second Opinion reviews are initiated by the agency or its contracted managed care organization when a pharmacy requests authorization. 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..