Prior Authorization Policies for Pediatric ADHD Medicati

Prior Authorization Policies for Pediatric ADHD Medication
Prescriptions
Form Approved
OMB No. 0920-0879
Expiration Date 03/31/2018

Instructions
Welcome! This information collection is meant for state Medicaid Medical Directors, or their designee, with
knowledge of state Medicaid policies related to pediatric attention-deficit/hyperactivity disorder (ADHD)
treatment. The Policy Surveillance Program at Temple University Beasley School of Law (PSP) and the Centers
for Disease Control and Prevention (CDC) have already begun collecting information about your state’s
Medicaid policies from publicly available sources. The purpose of this questionnaire is to verify that we collected
the most up-to-date and accurate information from your state.
Your feedback is important to us. Your participation will help us identify where and why there are gaps in Medicaid
reimbursement related to ADHD treatment, which will allow us to conduct more precise analyses on the impacts of
these policies.
Completing the questionnaire is voluntary and takes approximately 20 minutes. Please note that any personally
identifiable information about respondents related to their official duties (name, position, agency, phone, and email)
will be removed when the results of this questionnaire are aggregated for analysis. Responses will be kept secure
and will not be shared with other respondents or other entities. There are no known risks or direct benefits to you
from participating or choosing not to participate, but your answers will help CDC improve its understanding of
Medicaid policies that influence pediatric ADHD treatment and might help other states develop or improve their
policies.
If you have any questions or concerns about this assessment, please email the CDC at [email protected].
To begin, please proceed to page 2 of this instrument.
When you have completed this survey, please click the SUBMIT button on page 1 or email as an attachment to
[email protected].
CDC estimates the average public reporting burden for this collection of information as 20 minutes per response, including the time for
reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing
and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection
of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect
of this collection of information, including suggestions for reducing burden to CDC/ATSDR Information Collection Review Office, 1600
Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0879).

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Section A.
The Temple PSP and CDC have compiled information on ADHD prior authorization policies across all states and the
District of Columbia. For the purposes of responding to all questions below, a prior-authorization policy is defined as
any policy that requires prior authorization, additional review, or other additional prescriber involvement for obtaining
approval and payment for ADHD medications prescribed to children younger than age 18 years.
The policy information we have compiled should reflect what was accurate for your jurisdiction as of November 1,
2015.
1. Please review Appendix A to verify the prior authorization policy information we collected for your state. Is
the information listed in Appendix A the most up-to-date policy in your state?
Yes
No, we have updated our policy since November 1, 2015
No, we did not have a policy on November 1, 2015, but we now have a policy
No, the policy you have provided is incorrect
Other
If your state Medicaid program does NOT currently have any prior-authorization policy limiting ADHD
medication prescriptions to children younger than age 18 years, PLEASE SKIP AHEAD TO SECTION B.
If you answered “No” to question 1, please email a copy of the most recent version of your state’s policy to
[email protected], and include the policy’s effective date.

2. Please review Appendix B to verify the table listing characteristics of your state’s policy. Are all of the
responses correct as of November 1, 2015?
Yes
No, at least one response is not correct as of November 1, 2015
Unsure whether all responses are correct as of November 1, 2015
If you answered “Yes” to question 2, please skip question 3 and continue to question 4.

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3. Please indicate below which questions you believe we did not correctly answer in Appendix B. Then,
please add an explanation in the box to the right.
Questions from Appendix B:
Does your state Medicaid program have a policy that
requires prior authorization for ADHD medications
prescribed to children younger than age 18 years?

The answer to this question in Appendix B is
not correct.

Please explain.

Which ages require prior authorization?

The answer to this question in Appendix B is
not correct.
Please explain.

Does the policy automatically deny authorization for
certain ages?

The answer to this question in Appendix B is
not correct.

Please explain.

Does the policy specify ADHD medications that require
prior authorization?

The answer to this question in Appendix B is
not correct.

Please explain.

Are stimulants included?

The answer to this question in Appendix B is
not correct.
Please explain.

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Question from Appendix B (continued):
Reminder: If you answered “Yes” to question 2, please skip question 3 and continue to question 4.
Are non-stimulants included?

The answer to this question in Appendix B is
not correct.
Please explain.

Does the policy list criteria for approval?

The answer to this question in Appendix B is
not correct.
Please explain.

The answer to this question in Appendix B is
not correct.

What criteria are listed to receive approval?
Please explain.

4. How is the prior-authorization approval process triggered in your state?
At the medication’s point-of-sale
When the prescriber submits a prior-authorization form to a reviewing body
Other (please explain)
5. Is the prior-authorization request peer-reviewed by medical experts?
Yes
No
Don’t know
Other (please explain)
6. When was the very first prior authorization policy implemented in your state for children younger than
18 years old? (Please indicate "unsure" if you do not know the date.)

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7. Has your program ever evaluated this prior authorization policy’s effect on prescription rates?
Yes
No
Don’t know
If yes, please explain below.

Section B.
Please answer the following additional questions regarding behavioral health carve-outs for services provided
to children (< age 18 years) in your state Medicaid program.
8. Does your state Medicaid program currently carve out behavioral or mental health services provided to
children?
Yes
No
Don’t know
If you answered “No” to question 8, please skip to question 11.
9. If your Medicaid program currently carves out any behavioral or mental health services for children, which
services are carved out?
Outpatient behavioral/mental health services
Inpatient behavioral/mental health services
Prescription drugs
Substance abuse services
Other (please explain)
10. How are they carved out?
Carved out to a fee-for-service delivery system
Carved out to a behavioral health organization
Other (please explain)

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11. Please complete the following matrix to indicate if your state has ever carved out children’s behavioral
health services in the past five years.
Not Carved Out

Carved Out

Unsure

2015
2014
2013
2012
2011
2010

12. Please use this space to provide additional comments about the dates of your state’s carved
out behavioral health services in the past five years, if necessary.

Please contact CDC with any questions, or to discuss your state’s Medicaid program in greater detail.
Contact Information
13. Please provide the following information about the person who completed this survey:
First Name:

Last Name:

Job Title:

Description of your position:

State:

Department:

E-mail:

Phone:

14. Has this survey been delegated to you by the Medicaid Director or Medicaid Medical Director in
your state?
Yes
No
Don’t know
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15. Please use this section to provide any additional comments or information about your state
Medicaid program’s policies related to ADHD medication prescription to children under age 18 years
and/or behavioral health services carve outs. You may also email CDC to share any additional
information.

When you have completed this survey, please click the SUBMIT button on page 1 or email as an
attachment to [email protected].

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APPENDIX A
Click here to return to question 1.

Prior Authorization Guidelines
ADHD Medications in Children Under 6 Years Old
FDA Approved Indication:
Treatment of Attention Deficit Hyperactivity Disorder (ADHD)
Guidelines for Approval:
1. The requesting clinician has documented that the child has a diagnosis of ADHD
2. Psychosocial issues and non-medical interventions are being addressed by the clinical team.
3. Documentation of psychosocial evaluation occurring before request for ADHD medications.
4. Documentation of non-medication alternatives that have been attempted before request for
ADHD medications.
Additional Requirements:
Children under 6 years old will be monitored in accordance with the ADHS/DBHS Clinical Practice
Protocol on Psychiatric Best Practice Guidelines for Children: Birth to Five Years of Age.
Coverage is Not Authorized for:
1. Indications other than ADHD.
2. Doses greater than FDA recommended maximum daily dosage.
References:
1. ADHS/DBHS: Provider Manual Section 3.15: Psychotropic Medication: Prescribing and
Monitoring
2. Manufacturer Product Information
3. Pliska SR, Greenhill LL, Crismon ML, et al. The Texas children’s medication algorithm project:
report of the Texas census conference panel on medication treatment of childhood deficit/
hyperactivity disorder. Part 1. J Am Academy Child Adolescent Psychology.
200;39(7):920-927
Finalized 8/5/2013

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APPENDIX B
Click here to return to question 2.
Click here to return to question 3.

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