Questions and Answers
What is the goal of this initiative?
The MassHealth Pediatric Behavioral Health Medication Initiative focuses on safe prescribing practices for behavioral health medication regimens in MassHealth members younger than 18 years of age. The initiative includes prior authorization requirements for select classes of behavioral health medication effective November 24, 2014.
How were the MassHealth Pediatric Behavioral Health Medication Initiative guidelines created, given that current consensus guidelines do not specifically address behavioral health medication polypharmacy and age restrictions in the pediatric population?
The MassHealth Pediatric Behavioral Health Medication Initiative 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 prior authorization requests submitted to the MassHealth Drug Utilization Review 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 antidepressants, antipsychotics, antianxiety agents, alpha2 agonists, cerebral stimulants, hypnotics, and mood stabilizers. A comprehensive medication list and additional information about the MassHealth Pediatric Behavioral Health Medication Initiative, including prior authorization requirements, are available on the MassHealth Drug List webpage at www.mass.gov/druglist.
Who will be affected by the MassHealth Pediatric Behavioral Health Medication Initiative?
MassHealth members younger than 18 years of age will be affected by this initiative. Currently, this initiative does not include MassHealth MCO members.
When will the prior authorization requirements for the Pediatric Behavioral Health Medication Initiative take effect?
Several of these requirements went into effect on November 24, 2014. These included prior authorization requirements for
- Alpha2 agonist or cerebral stimulant pharmacy claims for members younger than three years of age;
- Antidepressant, antipsychotic, atomoxetine, benzodiazepine, buspirone, or mood stabilizer pharmacy claims for members younger than six years of age; and
- Hypnotic or hypnotic benzodiazepine pharmacy claims for members younger than six years of age.
Polypharmacy requirements that are generally applicable to members younger than 18 years of age became effective on February 23, 2015, to allow for a grace period for clinically appropriate medication regimen changes.
Will prescriptions written prior to the start of this initiative be grandfathered?
Prescriptions written prior to November 24, 2014, will be grandfathered for the remainder of refills. A new prior authorization will be required upon prescription expiration, depletion of refills, and/or any change in medication regimen. Prescriptions written on or after November 24, 2014 and new prescriptions for members whose earlier prescriptions were grandfathered will require prior authorization.
How will prescribers know what information needs to be submitted for a prior authorization?
A new Pediatric Behavioral Health Medication Initiative Prior Authorization form, a comprehensive medication list, additional information about the MassHealth Pediatric Behavioral Health Medication Initiative, including prior authorization requirements, as well as 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 prior authorization form for the MassHealth Pediatric Behavioral Health Medication Initiative?
Yes. The MassHealth Pediatric Behavioral Health Medication Initiative Prior Authorization form is available on the MassHealth Drug List webpage at www.mass.gov/druglist. Additionally, existing behavioral health medication class prior authorization forms (e.g., antidepressants, antipsychotics, cerebral stimulants, hypnotics, anticonvulsants) have a new section related to the MassHealth Pediatric Behavioral Health Medication Initiative that must be completed on behalf of members younger than 18 years of age. Either the MassHealth Pediatric Behavioral Health Medication Initiative Prior Authorization form or the applicable behavioral health medication class prior authorization form(s) may be submitted for review.
Will a prior authorization request need to be submitted for every behavioral health medication?
No. Prior authorization requests will be required for
(a) members younger than 18 years of age 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
(b) specific behavioral health medications prescribed in the very young (i.e., members younger than three years of age or six years of age, depending on the medication class). Please Note: Prior authorization 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 Pediatric Behavioral Health Medication Initiative, including prior authorization requirements, is available on the MassHealth Drug List webpage at www.mass.gov/druglist.
Are any resources available to aid prescribers in determining which members will be affected by this initiative?
The MassHealth Drug Utilization Review (DUR) Program can provide prescribers with a list of members for whom the prescriber has (a) provided treatment and (b) may be affected by this initiative. Prescribers may request this list by contacting the DUR program at 1-800-745-7318.
Can prescribers submit prior authorization requests on behalf of members who are not currently affected by this initiative but whose treatment regimens may require prior authorization at a future time?
Yes. Prescribers may submit prior authorization requests on behalf of members prior to 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 prior authorization 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, three or more mood stabilizers), as well as the use of four or more behavioral health medications in a regimen, whether within the same medication class or across different behavioral health medication classes.
How are age requirements defined for this initiative?
There are three categories of age requirements applicable to this initiative. Members less than 18 years of age 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). In addition, members less than six years of age who are prescribed an antidepressant, antipsychotic, atomoxetine, benzodiazepine, buspirone, hypnotic, or mood stabilizer may require prior authorization. Finally, members less than three years of age who are prescribed an alpha2 agonist or cerebral stimulant will require prior authorization. A comprehensive medication list and additional information about the MassHealth Pediatric Behavioral Health Medication Initiative, including prior authorization requirements, is available on the MassHealth Drug List webpage at www.mass.gov/druglist.
How is a mood stabilizer defined for this initiative?
Mood stabilizers include all anticonvulsants as these medications may be used for behavioral health indications. Lithium is also classified as a mood stabilizer under this initiative.
Are there any prescriber restrictions for prior authorization requests for this initiative?
All prescribers may submit prior authorization requests on behalf of the member. Prior authorization requirements for certain medications include a specialist prescriber or a consultation from a specialist. For all mid-level practitioners prescribing medications through a collaborative agreement, documentation that the collaborating physician is a specialist or documentation of a specialist consultation is required.
How is a specialist defined for this initiative?
Prescribers will be considered specialists depending on the health condition that is being treated (e.g., 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 prior authorization request.
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 prior authorization 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 prior to the date of the request.
Will a prior authorization request need to be submitted when a medication changes in the behavioral health regimen?
Prior authorization 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 prior authorizations 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 prior authorization requests prior to implementing medication changes to avoid disruption in therapy.
Will prior authorization 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 prior authorization 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 prior authorization if polypharmacy and/or age requirements are implicated, and
(a) the member has a psychiatric diagnosis history or
(b) the medication has a behavioral health indication.
Prescribers are encouraged to document the diagnoses and corresponding treatment plan clearly, including all current medications, as this information will be taken into consideration during review of prior authorization requests.
If there is more than one prescriber involved in the behavioral health medication regimen, which prescriber would be responsible for submitting the prior authorization 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 prior authorization request. The prescriber who submits the prior authorization 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 prior authorization request.
Will member care be disrupted if the prior authorization 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 prior authorization requests submitted under the MassHealth Pediatric Behavioral Health Medication Initiative?
The duration of a prior authorization approval and of a recertification may be up to 12 months, depending on the clinical situation.
What is a provisional prior authorization approval?
A prior authorization request may be approved provisionally for duration of up to three months depending on the clinical situation. Prior authorization 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 via fax and/or telephone.
What happens when the member reaches his or her 18th birthday?
The MassHealth Pediatric Behavioral Health Medication Initiative focuses on members less than 18 years of age. Once members exceed this age requirement, the prior authorization restrictions of the initiative will no longer apply; however, members will still be subject to any other prior authorization 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 Pediatric Behavioral Health Medication Initiative (PBHMI), please contact the Drug Utilization Review Program at 1-800-745-7318.
If you have comments about the PBHMI, contact the Drug Utilization Review Program at 1-800-745-7318 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 e-mails but will use this feedback for further improvements to the Pediatric Behavioral Health Medication Initiative. This mailbox is dedicated to questions or comments about the MassHealth Pediatric Behavioral Health Medication Initiative only.
You can also find more information about the MassHealth Pediatric Behavioral Health Medication Initiative here, including the prescriber letter, clinical document, therapeutic class tables, and prior authorization forms.
For MassHealth Members
If you have questions about the MassHealth Pediatric Behavioral Health Medication Initiative, please call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648).