Early and Periodic Screening, Diagnostic, and Treatment Benefits for Pediatric Members
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Defines coverage, medical necessity criteria, and approval processes for EPSDT services and medications for Medicaid members under age 21 enrolled with Arizona Complete Health (AzCH-CCP and Care1st). Affects providers requesting EPSDT-covered interventions and medications for pediatric members.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Initial Approval Criteria — Medication Request Through EPSDT Benefit
Medication requests through the EPSDT benefit are covered when ALL of the following are met:
Continued Therapy Criteria — Medication Request Through EPSDT Benefit
Continued therapy is covered when ALL of the following are met:
EPSDT services do not include services that are experimental, that are solely for cosmetic purposes, or that are not cost effective when compared to other interventions or treatments.
Requests for medications under the EPSDT benefit must meet medical necessity and may be denied when the agent or prescribed dose is experimental or investigational for the member’s diagnosis or age. Providers must demonstrate that the requested agent and dose are appropriate for the pediatric member, that alternatives have been tried when required, and that the intervention meets the EPSDT standards for authority, purpose, scope, evidence, and value.
Provider Responsibilities and Prior Authorization
EPSDT medication prior authorization requirements
Medication requests for members under EPSDT (<21 years) require prior authorization and must meet initial approval criteria. Providers must submit a complete prior authorization request including supporting clinical documentation. Requests that do not meet the criteria or lack required documentation will be denied.
- Prior authorization required for EPSDT medication requests (Age < 21).
- Medication must meet drug-specific initial approval criteria or, if none exists, general medical necessity policies.
- Formulary alternatives must be tried and documented unless contraindicated, not tolerated, or unavailable.
- Requested agent/dose must not be experimental/investigational for the member's diagnosis and age.
- Approval duration: 6 months.
Formulary alternative failure requirement
Providers must document failure of formulary alternatives when required by the drug-specific or general medical necessity policy. If alternatives were not tried due to clinically significant adverse effects, contraindications, or lack of alternatives, include documentation explaining the reason.
- List of tried formulary medications with dates and reasons for discontinuation.
- Documentation of adverse effects or contraindications when alternatives were not tried.
Required clinical documentation
Submit complete clinical documentation to support that the member meets all approval criteria. Acceptable documentation includes office/chart notes, laboratory results, diagnostic testing, medication history, and physician rationale tying clinical findings to medical necessity.
- Office visit notes describing diagnosis, symptoms, and prior treatments.
- Relevant lab or diagnostic test results.
- Medication history including dates, doses, and reasons for discontinuation of prior therapies.
- Physician statement supporting medical necessity and expected benefit.
Documentation-driven denials
Requests missing required documentation or not meeting medical necessity, formulary, or EPSDT criteria will be denied. Denials are documentation-driven; include all supporting records with the initial submission to avoid delays or denials.
- Incomplete or absent office notes, labs, or medication history may result in denial.
- Requests for non‑PDL or excluded products must show trial and failure of alternatives or a documented contraindication.
- If drug-specific criteria exist, the request must meet those criteria or it will be denied.
Key Definitions
Background and Policy Scope
The purpose of EPSDT is to ensure availability and accessibility of comprehensive preventive, diagnostic, and treatment services for Medicaid members under 21 years of age. Federal EPSDT requirements support coverage of medically necessary services that detect, correct, or ameliorate physical and behavioral health conditions for this pediatric population.
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