MHCP Enrolled Providers

Pharmacy Program

Final Psych Consult Dose Thresholds

M.S. 245.4862 and 256B.0625

Recent Developments

Effective June 1, 2014, psychiatric consultations will no longer be required for high-dose ADHD and SGA drugs prescribed for children over age 3. Instead, pharmacies will receive an informational point-of-service (POS) message when they bill for prescriptions which exceed the dose/age threshold for recipients under age 18.

Also, as of June 1, 2014, a child must be at least three years old for all ADHD and SGA prescriptions. Prior authorization (PA) overrides will not be available for children younger than age 3. Some drugs will continue to be subject to higher age requirements. PA requirements for prescription drugs, including age requirements for prescription drugs, are available on the PA Criteria and Regimen Review Sheets.

Psychiatric Consultation Process - Phase One

To initiate or continue psychotropic drug therapy in children at dosages exceeding the thresholds listed in Tables 1 and 2, providers must complete a Collaborative Psychiatric Consultation with the Minnesota Collaborative Psychiatric Consultation Service as part of the prior authorization process. The consultations are provided by board certified child and adolescent psychiatrists.

This program will be implemented in phases, and all medications listed in Tables 1 and 2 will eventually be affected. The implementation dates and consultation requirements are listed below:

September 17, 2012:

Second generation antipsychotics (SGA) prescribed for children age five and younger

February 4, 2013:

Second generation antipsychotics (SGA) prescribed for children over the age of five starting next with 6-12 years

August 5, 2013:

ADHD drugs as listed in Table 2 below starting with youngest age groups first


After the first three phases are implemented, the service will be expanded to require consultations for all drugs in Tables 1 and 2 beginning with the youngest age groups and adding subsequent age groups as service capacity is readied.

Two exceptions to an immediate, mandatory consultation are allowed:

1.

The prescriber indicates that the child has already been stabilized on the medication regimen

2.

The prescriber indicates that the child is in crisis

In the above situations, a prior authorization may be granted for up to 90 days, allowing time for the consultation to be completed.

Beginning September 17, 2012

Claims for SGA medications for children age five and younger will reject at the point of sale if a consultation has not been completed prior to claim submission. The rejection displayed will be reason code 340: “recipient’s age less than minimum specified on drug record.”

PHARMACY PROCESS

For rejected pharmacy claims DHS recommends that pharmacies do the following:

1.

Notify the prescriber that a consultation is required to override the age edit.

2.

Provide the prescriber with the Psychiatric Consultation Request Form (DHS-6176) and/or the Minnesota Collaborative Psychiatric Consultation Service phone number 1-844-431-6468.

CONSULTATION AND APPROVAL PROCESS

When prescribing a SGA in a child five years of age or younger, prescribers should:

1.

Fax the completed Psychiatric Consultation Request Form (DHS-6176) to the Minnesota Collaborative Psychiatric Consultation Service at 1-855-433-4276.

2.

Call the Consultation Service at 1-855-431-6468 to complete the Consultation.

After the consultation has taken place, the Consultation Service will contact the pharmacy to obtain or verify the appropriate drug NDC and the pharmacy NPI information. The Consultation Service forwards the consultation results and completed Psychiatric Consultation Form to the MHCP Prescription Drug Prior Authorization Agent. Within 24 hours the Prior Authorization Agent will notify the prescriber and pharmacy by fax of approved and denied prior authorizations. The recipient is notified by letter generated the next day from DHS.

The Minnesota Collaborative Psychiatric Consultation Service can be reached at 1-855-431-6468 Monday through Friday from 7 a.m. to 7 p.m.


Table 1. Second Generation Antipsychotics Max Allowed Thresholds (Excludes Injectable Formulations)

Drug

Max MG per DAY Allowed Without Consultation

≤ 5 yrs

6-12 yrs

13-17 yrs

Risperidone (Risperdal)

0

3

6

Aripiprazole (Abilify)

0

10

20

Quetiapine (Seroquel & Seroquel XR)

0

300 (6-9 yrs)
600 (≥10 yrs)

600

Olanzapine (Zyprexa)

0

0

10

Ziprasidone (Geodon)

0

80

120

Clozapine (Clozaril)

0

0

600

Paliperidone (Invega)

0

0

6

Iloperidone (Fanapt)

0

0

0

Asenapine (Saphris)

0

0

0

Lurasidone (Latuda)

0

0

0


Table 2. ADHD Drugs Max Allowed Thresholds

Drug

Max MG per DAY Allowed Without Consultation

≤ 3 yrs

4-5 yrs

6-9 yrs

10-12 yrs

13-17 yrs

Methylphenidate

0

40

80

108

108

Dexmethylphenidate

0

20

40

50

50

Mixed amphetamine

0

20

40

60

60

Dextroamphetamine

0

20

40

60

60

Lisdexafetamine

0

50

70

70

70

Atomoxetine

0

0

100

100

100

Clonidine

0

0.2

0.4

0.4

0.4

Guanfacine

0

2

4

4

4


Psychiatric Consultation Request Form (DHS-6176): for prescribers to transmit to the Psychiatric Consultation Service

Additional information: www.dhs.state.mn.us/psychconsult

Legal reference: legislation


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