What is the goal of this initiative?
The MassHealth Pediatric Behavioral Health Medication Initiative (PBHMI) focuses on safe prescribing practices for behavioral health medication regimens in MassHealth members younger than 18. The initiative includes prior authorization (PA) requirements for select classes of behavioral health medication effective November 24, 2014.
How were the MassHealth PBHMI guidelines created, given that current consensus guidelines do not specifically address behavioral health medication polypharmacy and age restrictions in the pediatric population?
The MassHealth PBHMI guidelines were created using evidence-based medicine and recommendations from an expert workgroup primarily composed of child and adolescent psychiatrists. This group was convened by the Department of Mental Health and served as an advisory board to the MassHealth Pharmacy Program. The approval criteria that will be used to evaluate PA requests submitted to the MassHealth Drug Utilization Review (DUR) Program were developed in consultation with this workgroup, to ensure appropriate behavioral health medication use in pediatric members.
What types of medications will be affected by this initiative?
The behavioral health medication classes affected by this initiative include alpha2 agonists, antidepressants, antipsychotics, armodafinil, atomoxetine, benzodiazepines, buspirone, cerebral stimulants, donepezil, hypnotic agents, memantine, meprobamate, modafinil, mood stabilizers (agents considered to be used only for seizure diagnoses are not included), naltrexone, prazosin, and viloxazine. A comprehensive medication list and additional information about the MassHealth PBHMI, including PA requirements, are available on the MassHealth Drug List web page at www.mass.gov/druglist.
Who will be affected by the MassHealth PBHMI?
MassHealth members younger than 18 will be affected by this initiative.
How will prescribers know what information needs to be submitted for a PA?
A Pediatric Behavioral Health Medication Initiative Prior Authorization form; a comprehensive medication list; additional information about the MassHealth PBHMI, including PA requirements; and updated forms for designated behavioral health medication classes are available on the MassHealth Drug List webpage at www.mass.gov/druglist.
Is there a specific PA form for the MassHealth PBHMI?
Yes. The MassHealth Pediatric Behavioral Health Medication Initiative Prior Authorization Request form is available on the MassHealth Drug List webpage at www.mass.gov/druglist. Additionally, existing behavioral health medication class PA forms (e.g., antidepressants, antipsychotics, cerebral stimulants, hypnotics, anticonvulsants) have a section related to the MassHealth PBHMI that must be completed on behalf of members younger than 18. Either the MassHealth Pediatric Behavioral Health Medication Initiative Prior Authorization form or the applicable behavioral health medication class PA form(s) may be submitted for review.
Will a PA request need to be submitted for every behavioral health medication?
No. PA requests will be required for:
- Members younger than 18 who are prescribed specific behavioral health medication regimens, including polypharmacy among the same behavioral health medication class and/or across different behavioral health medication classes, or
- Specific behavioral health medications prescribed in the very young (i.e., members younger than three, six, or 10, depending on the medication class). Please note: PA requirements that generally affect all MassHealth members (e.g., brand name medications, quantity limits) remain in effect.
A comprehensive medication list and additional information about the MassHealth PBHMI, including PA requirements, is available on the MassHealth Drug List web page at www.mass.gov/druglist.
Can prescribers submit PA requests on behalf of members who are not currently affected by this initiative, but whose treatment regimens may require PA at a future time?
Yes. Prescribers may submit PA requests on behalf of members before the implementation of a change in the member’s treatment regimen. Prescribers are encouraged to clearly document the diagnoses and corresponding treatment plan, including all current medications and planned medication changes, as this information will be taken into consideration during review of PA requests.
How is polypharmacy defined for this initiative?
Polypharmacy is defined as the use of:
- More than one agent within the same medication class (e.g., two or more antidepressants, two or more antipsychotics, three or more mood stabilizers, etc.), as well as
- Four or more behavioral health medications in a regimen, whether within the same medication class or across different behavioral health medication classes, when certain medications are included in the regimen (e.g., an antipsychotic, a benzodiazepine, divalproex/valproate, lithium, or a tricyclic antidepressant), or
- Five or more behavioral health medications in a regimen, regardless of the medications included.
How are age requirements defined for this initiative?
There are four categories of age requirements applicable to this initiative.
- Members younger than 18 who are prescribed specific behavioral health medication regimens may be subject to polypharmacy restrictions (e.g., behavioral health medications within the same class and/or across different medication classes).
- Members younger than 10 who are prescribed an antipsychotic may require PA.
- In addition, members younger than six who are prescribed an antidepressant, armodafinil, atomoxetine, benzodiazepine, buspirone, donepezil, hypnotic, memantine, meprobamate, modafinil, mood stabilizer (agents considered to be used only for seizure diagnoses are not included), naltrexone, prazosin, or viloxazine may require PA.
- Finally, members younger than three who are prescribed an alpha2 agonist or cerebral stimulant will require PA.
A comprehensive medication list and additional information about the MassHealth PBHMI, including PA requirements, is available on the MassHealth Drug List web page at www.mass.gov/druglist.
How is a mood stabilizer defined for this initiative?
Mood stabilizers include anticonvulsants that may be used for behavioral health indications (agents considered to be used only for seizure diagnoses are not included). Lithium is also classified as a mood stabilizer under this initiative.
Are there any prescriber restrictions for PA requests for this initiative?
All prescribers may submit PA requests on behalf of the member. PA requirements for certain medications include a specialist prescriber or a consultation from a specialist. For mid-level practitioners prescribing medications through a collaborative agreement, documentation that the collaborating physician is a specialist or documentation of a specialist consultation may be required.
How is a specialist defined for this initiative?
Prescribers will be considered specialists depending on the health condition that is being treated (for example, a child psychiatrist is considered a specialist for a certain behavioral health conditions; a neurologist is considered a specialist for a seizure-related condition). For mid-level practitioners who specialize in pediatric behavioral health conditions, documentation that the collaborating physician is a specialist or documentation of a specialist consultation from a physician is required upon submission of a PA request, if applicable.
How is a specialist consultation defined for this initiative?
A specialist consultation is defined as any communication between the prescriber and a specialist regarding a specific member’s behavioral health condition(s) and treatment regimen. This includes, but is not limited to, a telephone consultation or an in-person member evaluation by a specialist. Psychiatry consultations dated within the last year are acceptable.
The consultation must be documented on the PA form with the name and specialty of the specialist and the date of the consultation. The consultation must have occurred within one year of the date of the request. Provisional approvals may be considered if the consultation date is not provided or took place more than one year before the date of the request.
Will a PA request need to be submitted when a medication changes in the behavioral health regimen?
PA may be required for members with a change in therapy if polypharmacy or age requirements are implicated by the medication change. In most circumstances, dose changes will not affect PAs once approved. Prescribers who need to cross-taper or titrate medications should clearly document the dosing plan so that DUR can facilitate those changes. Prescribers are encouraged to submit PA requests before implementing medication changes to avoid disruption in therapy.
Will PA be required if the member requires treatment for non-behavioral health conditions (e.g., seizures, migraines, neuropathic pain)?
If the medication is prescribed for a non-behavioral health indication but is considered a behavioral health medication by classification under the initiative, the regimen may require PA if polypharmacy and/or age requirements are implicated. If the medication is prescribed for a member with non-behavioral health conditions only, the regimen may require PA if polypharmacy and/or age requirements are implicated, and
- The member has a psychiatric diagnosis history, or
- The medication has a behavioral health indication.
Prescribers are encouraged to clearly document the diagnoses and corresponding treatment plan, including all current medications, as this information will be taken into consideration during review of PA requests.
If there is more than one prescriber involved in the behavioral health medication regimen, which prescriber would be responsible for submitting the PA request on behalf of the member?
Coordination of care between prescribers is strongly encouraged to ensure safe and effective prescribing practices. Any prescriber involved in the member’s care may submit the PA request. The prescriber who submits the PA request is encouraged to coordinate with all other prescribers for the member and clearly document the diagnoses and corresponding treatment plan, including all current medications, on the PA request.
Will member care be disrupted if the PA request has not been submitted or processed before the prescription is filled?
Emergency supplies of medications will be available to avoid disruption in therapy. The prescriber, member, and/or member’s caregiver may request an emergency supply of medication at the member’s pharmacy. Emergency supplies of medications are available for any clinically appropriate duration of therapy, up to 30 days. There is no limit to the number of subsequent emergency supplies of medications, if such supplies are medically necessary.
What is the approval duration for PA requests submitted under the MassHealth PBHMI?
The duration of a PA approval and of a recertification may vary from one to 12 months, depending on the clinical situation.
What is a provisional PA approval?
A PA request may be approved provisionally, depending on the clinical situation. For example, PA requests may be approved provisionally to avoid disruption in therapy when additional clinical documentation is required from the prescriber. In circumstances where additional clinical documentation is required, prescribers will be notified by fax or telephone or both.
What happens when the member reaches their 18th birthday?
The MassHealth PBHMI focuses on members younger than 18. Once members exceed this age requirement, the PA restrictions of the initiative will no longer apply; however, members will still be subject to any other PA requirements that generally affect all MassHealth members.
Who can answer additional questions?
For Pharmacists and Prescribers
If you have questions about a specific patient or claim affected by the MassHealth PBHMI, please contact the Drug Utilization Review Program at (800) 745-7318.
If you have comments about the PBHMI, contact the Drug Utilization Review Program at (800) 745-7318 or email the MassHealth Pharmacy Program at pbhmifeedback@umassmed.edu. Please include your name, title, phone number, and fax number.
Please note: MassHealth will not answer all emails, but will use this feedback for further improvements to the PBHMI. This mailbox is dedicated to questions or comments about the MassHealth PBHMI only.
You can also find more information about the MassHealth PBHMI on the PBHMI Information page, including the prescriber letter, clinical document, therapeutic class tables, and PA forms.
For MassHealth Members
If you have questions about the MassHealth PBHMI, please call MassHealth at (800) 841-2900, TDD/TTY: 711.
| Date published: | October 1, 2024 |
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