Provider Notice issued 08/03/09

Prior Approval for Atypical Antipsychotics and ADHD Medications for Young Children

Nationally, and within Illinois, there is growing concern related to potential overuse of mental health drugs in children. The Department of Healthcare and Family Services, in consultation with leading psychiatrists from Illinois' teaching centers, has engaged in an extensive review of the utilization patterns of mental health drugs in very young children.  As a result of that consultation and discussion, the department has decided to require prior approval for ADHD

medications for children under the age of 6, and for atypical antipsychotics for children under the age of 8. 

The goals of the prior authorization process are to:

• Provide support to physicians when they have complex clinical situations, including providing consultant child/adolescent psychiatrists

• Ensure appropriate access to medication for severely impaired young children resistant to non-pharmacological intervention

• Ensure that very young children receiving psychopharmacological agents are on the appropriate doses

• Reduce the inappropriate use of psychopharmacological agents in very young children

• Allow the department the opportunity to better understand the utilization of mental health drugs in these children. 

Further, a Child and Adolescent Behavior Health Consultation Program is now available for providers who wish to consult with a child and adolescent psychiatrist regarding their patients.  This service is available at no charge.  The hotline number is: 1-866-986-2778.  The Web site is http://www.psych.uic.edu/DOCASSIST/   The department encourages providers to take advantage of this support.

In addition, the department would like to remind providers that a prescriber must obtain consent from DCFS prior to prescribing any psychotropic medications for a DCFS ward.  The prescriber must obtain consent from DCFS using the Psychotropic Medication Request form at http://www.state.il.us/DCFS/library/com_communications_forms.shtml

If HFS approves a prior approval request, this does not provide DCFS consent.  The provider must still obtain DCFS consent.

The department has developed specific prior authorization forms to request prior authorization for these drugs.  The forms are attached to this notice.  The department will notify the provider, via fax-back form, of the disposition of all prior authorization requests for these drugs.

The department encourages providers and discharge planners to request prior approval as part of the discharge planning process for hospitalized or institutionalized patients.  Requests for prior approval should be initiated prior to discharge in order to ensure a smooth transition into the community.

Some existing patients may be grandfathered for the short term.  This will allow the department to stagger the implementation of this change so that claims for all existing patients do not hit the prior approval edits the first month of implementation.  If a provider has a patient that will require prior approval, the provider should not wait for the patient’s claims to hit a prior approval edit at the pharmacy.  The provider should proceed with his or her request for prior approval as soon as possible.

If you have any questions concerning this notice, please contact your pharmacy billing consultant in the Bureau of Pharmacy Services toll-free at 1-877-782-5565, option 7.

Theresa A. Eagleson, Administrator

Division of Medical Programs

Atypical Antipsychotic Medications in Children <8 years Prior Authorization Request Form

ADHD Medication Prior Authorization Request Form (pdf)