Apple Health (Medicaid) - New dose limits of stimulant ADHD medications

Health Care Authority

Dear Provider:

Effective for dates of service on and after November 15, 2014, Washington Apple Health (Medicaid) administered by the Health Care Authority (agency), will implement new dose limits of stimulant ADHD medications for clients 17 years of age and younger based on the recommendations from the Pediatric Mental Health Work Group:

 

 

 

Age

 

 

Methylphenidate

 

 

Lisdexamphetamine

  

Amphetamines, Dexmethylphenidate,
Transdermal Methylphenidate

0 - 4 years of age

PA required

PA required

PA required

5 - 8 years of age

70mg

60mg

35mg

9 - 11 years of age

90mg

75mg

45mg

12 -17 years of age

120mg

100mg

60mg

As part of the authorization process, prescribers must consult by phone with an agency-designated mental health specialist from the Second Opinion Network (SON). To receive payment for the phone consultation with SON, use CPT® code 99441 on the claim.

Note: A SON representative will contact the prescriber(s) to schedule the required phone consultation.

At the time of the authorization request, continuation of therapy will be approved until the SON consultation process is complete. Agency authorization decisions will be based on recommendations to the agency by the SON mental health specialist.

CPT Copyright 2013 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Thank you.
Provider Publications Team
Washington Apple Health
Health Care Authority

NOTE: Please do not reply directly to this Listserv message. If you have feedback or questions, please visit the HCA website at http://www.hca.wa.gov/medicaid/Pages/contact.aspx. That way, your message can be delivered to the appropriate staff person.