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    v1.0.31
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsAdvanced Health EPSDT Prior Auth Coverage | OpenPa…
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    CurrentAdvanced HealthPolicy N/A

    Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Drug Use Criteria

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    This policy governs prior authorization review for medications requested for Advanced Health members age 20 and younger under EPSDT. It establishes formulary, FDA approval or compendium support, medical-severity, and medical-necessity requirements for coverage.

    Policy Summary
    PayerAdvanced Health
    PolicyEPSDT Drug Use Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Last ReviewApr 1, 2024
    Next Review DateN/A
    Key ActionWhen a formulary medication is available, request that the provider change the medication request to the formulary option before review proceeds.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    ≤20Member age range
    PA medicationsMedication scope
    12 monthsMaximum approval period
    FDA/compendiumRequired evidence

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    EPSDT Drug Coverage Review

    EPSDT Drug Coverage Review

    Apply the following decision sequence for a medication request:

    EPSDT medication coverage

    • Age eligibility: The member is younger than 21 years of age.Age < 21

      If the member is age 21 or older, route the request to the appropriate drug use criteria or deny as below the Oregon Health Plan funded line, if appropriate.

    • Formulary review: No formulary medication is available for the condition, or the provider changes the request to the available formulary medication.

      If a formulary medication is available, request a change to that medication before proceeding.

    • Supported indication: The requested medication has FDA approval for the condition being treated or is supported by a compendium.

      If neither is present, deny as not meeting criteria. Experimental or investigational medications are not a covered service.

    • Condition severity and health impact: Documentation shows that the condition is sufficiently severe to affect the member's health, including quality of life, function, growth, development, ability to participate in school, or ability to perform activities of daily living.

      If documented, approve for up to 12 months. If not documented, send for physician review to determine medical appropriateness and/or medical necessity.

    Experimental or investigational treatments, services, items, and medications are not required to be covered under EPSDT and are not covered services under this policy.

    Documentation must show that the member’s condition is of sufficient severity to affect health, including impacts on quality of life, function, growth, development, school participation, or activities of daily living. If sufficient severity is not established, the request is referred for physician review to determine medical appropriateness and/or medical necessity.

    Prior Authorization and Documentation Actions

    Prior Authorization

    EPSDT Prior Authorization Scope

    Prior authorization applies to all medications requiring prior authorization under the EPSDT drug use criteria. The criteria apply to Advanced Health members 20 years of age and younger.

    • Members age 20 and younger
    • All medications that require prior authorization
    Step Therapy

    Use the Formulary Medication First

    Before review of the requested medication, determine whether a formulary medication is available for the condition. If one is available, send the request back to the provider and request a change to the formulary medication.

    • Check for a formulary medication for the requested condition
    • If available, request that the provider change therapy to the formulary medication

    Unsupported block type: documentation

    Unsupported block type: documentation

    Unsupported block type: denial_risk

    Unsupported block type: step_therapy

    Denial Risk

    Unsupported or Experimental Use

    Deny the request when the medication lacks FDA approval for the requested condition and is not supported by a compendium. EPSDT does not require coverage of experimental or investigational treatments, and experimental or investigational medications are not a covered service.

    • No FDA approval or compendium support: deny as not meeting criteria
    • Experimental or investigational use: not covered under EPSDT

    EPSDT Policy Background

    EPSDT applies to members 20 years of age and younger and requires consideration of medically necessary treatment needs for children and adolescents. Medication requests are reviewed for formulary availability, FDA approval or compendium support, and documentation that the condition sufficiently affects the member’s health. EPSDT does not require coverage of experimental or investigational treatments, services, items, or medications.

    Key Definitions

    EPSDT
    TermEPSDT
    Full nameEarly and Periodic Screening, Diagnostic, and Treatment
    ApplicationApplies to members 20 years of age and younger and to all medications that require prior authorization.
    Experimental or investigational
    TermExperimental or investigational
    DefinitionTreatments, services, items, or medications that are not established as covered under EPSDT because they are experimental or investigational.
    Coverage contextExperimental or investigational treatments, services, items, or medications are not required to be covered under EPSDT and are not a covered service under this policy.

    Initial EPSDT Medication Therapy

    Initial EPSDT Medication Therapy

    Initial medication requests are evaluated using the following EPSDT decision sequence:

    Initial EPSDT medication request

    • Age eligibility: The member is younger than 21 years of age.Age < 21

      Requests for members age 21 or older follow the appropriate drug use criteria or may be denied as below the Oregon Health Plan funded line, if appropriate.

    • Formulary pathway: No formulary medication is available for the condition, or the provider changes the request to the available formulary medication.

      When a formulary medication is available, request a change to that medication before the request proceeds under these criteria.

    • Supported indication: The requested medication has FDA approval for the requested condition or is supported by a compendium.

      A medication that lacks FDA approval for the requested condition and is not supported by a compendium does not meet criteria; experimental or investigational medications are not covered.

    • Medical severity and functional impact: Documentation shows that the condition sufficiently impacts the member's health, including quality of life, function, growth, development, ability to participate in school, or ability to perform activities of daily living.

      If sufficient severity is not documented, send the request for physician review to determine medical appropriateness and/or medical necessity.

    Formulary Step Requirement

    StepRequirementAction
    1A formulary medication is available for the condition being requested.Send the request to the provider and request a change to the formulary medication before proceeding with the requested medication.
    Policy Summary
    PayerAdvanced Health
    PolicyEPSDT Drug Use Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Last ReviewApr 1, 2024
    Next Review DateN/A
    Key ActionWhen a formulary medication is available, request that the provider change the medication request to the formulary option before review proceeds.
    SourceLink
    On This Page
    EPSDT Drug Coverage ReviewPrior Authorization and Documentation ActionsEPSDT Policy BackgroundKey DefinitionsInitial EPSDT Medication TherapyFormulary Step Requirement