CurrentCareSourcePolicy AR-PAS-P-4041919

Antipsychotic Prescription Prior Authorization and Documentation Requirements for Members Under 18 (PASSE - Arkansas)

Defines prior authorization and documentation requirements for antipsychotic medications prescribed to CareSource PASSE members under age 18 in Arkansas, and aligns PASSE with Arkansas DHS Medicaid prescribing criteria.

Policy Summary

PayerCareSource

PolicyAntipsychotic Prescription Prior Authorization and Documentation Requirements for Members Under 18 (PASSE - Arkansas)

Policy CodePolicy AR-PAS-P-4041919

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit a completed pharmacy prior authorization form (via CoverMyMeds or fax 866-930-0019) plus recent glucose and lipid labs and a signed Medication Informed Consent Form for members under 18.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

under 18applies to

9 monthslab timeframe

Lithium & Depakoteexempt from PA

CoverMyMeds/faxsubmission channel

Coverage criteria for antipsychotic medications (members under 18)

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Initial prior authorization requirements

Covered when ALL of the following are submitted for antipsychotic prescriptions in members under 18

Submission requirements: 1) Completed pharmacy prior authorization form submitted via CoverMyMeds or fax to 866-930-0019; 2) Copy of glucose and lipid laboratory test results obtained within the past 9 months; 3) Signed Medication Informed Consent Form for members under 18.

Based on Arkansas Medicaid Prior Authorization criteria; CareSource PASSE aligns with DHS requirements

Lithium and divalproex (Depakote) do NOT require prior authorization for CareSource PASSE members under 18. These agents are identified in the policy as FDA‑approved and/or research‑supported alternatives for bipolar disorder and aggression and are exempt from the pharmacy PA requirements that apply to antipsychotic medications in this population.

Coding and laboratory monitoring requirements

Metabolic monitoring CPT codesmixed

See Table 2.3

CPT codes for glucose and lipid monitoring as listed in Arkansas Medicaid Prior Authorization Criteria

Lab recency — within 9 months

Lab recency requirementGlucose and lipid screening must be from within the past nine months

Source referenceArkansas Medicaid Prior Authorization Criteria — Antipsychotics, Oral (Table 2.3)

Applicable test typesGlucose and lipid panels required

What providers must do to obtain coverage

Prior Authorization

Pharmacy prior authorization required for antipsychotics in members under 18

Prior authorization is required for antipsychotic medications prescribed to CareSource PASSE members under age 18; submit a completed pharmacy prior authorization form and required supporting documentation per Arkansas Medicaid PA criteria.

PA requests may be submitted via the CoverMyMeds® portal or by fax to 866-930-0019.
Follow Arkansas DHS/Medicaid prior authorization criteria for antipsychotics in children.

Step Therapy

Lithium and divalproex exempt from PA

Lithium and divalproex (Depakote) do not require prior authorization and are noted as FDA‑approved and/or research‑supported treatment options for bipolar disorder and aggression.

These agents are listed as alternatives that are exempt from PA under the Arkansas guidance aligned with CareSource PASSE.

Documentation Required

Submit PA form, recent labs, and signed consent

Providers must submit a completed Pharmacy Benefit Prior Authorization Request Form and include copies of glucose and lipid lab results from within the prior nine months plus a signed Medication Informed Consent Form for members under 18.

PA form submission channels: CoverMyMeds® portal or fax 866-930-0019.
Include glucose and lipid screening results from the past nine months (see Arkansas Medicaid Prior Authorization Criteria Table 2.3 for CPT codes).
Attach a signed Medication Informed Consent Form (required for members under 18).

Denial Risk

Risk of pharmacy rejection for missing PA requirements

Antipsychotic prescriptions for members under 18 are frequently rejected at the pharmacy when Arkansas Medicaid PA requirements are not met; missing the PA form, required labs, or the signed consent can trigger rejection.

Verify PA submission and that glucose/lipid labs (within 9 months) and Medication Informed Consent are included to avoid pharmacy rejections.

Background and rationale

Antipsychotics are commonly prescribed to children and adolescents for behavioral or psychiatric conditions but are subject to Arkansas Medicaid prior authorization to ensure appropriate use and monitoring. CareSource PASSE aligns with Arkansas DHS requirements because antipsychotic prescriptions for members under 18 are frequently rejected at the pharmacy if PA criteria are not met. Providers should follow the Arkansas Medicaid guidance and the practice parameters and FDA prescribing information referenced in the policy when assessing and treating aggression or other behavioral health indications in this age group.

Key definitions and required forms

Signed consent required for antipsychotic use in members under 18 — Medication Informed Consent Form

Signed consent requiredA signed Medication Informed Consent Form is required for members under 18 prescribed antipsychotics

Submission with PAThe completed Medication Informed Consent Form must be submitted with the pharmacy prior authorization request

PurposeDocuments informed parental/guardian consent for antipsychotic treatment in minors

Glucose and lipid screening within prior nine months — Required metabolic monitoring

Required metabolic monitoringCopy of glucose and lipid lab tests within the past nine months must be submitted for antipsychotic PA requests

CPT coding referenceSee Table 2.3 in Arkansas Medicaid Prior Authorization Criteria for CPT codes for glucose and lipid monitoring

AlignmentRequirement aligns CareSource PASSE with Arkansas Medicaid PA criteria

Medication management and alternatives

Medication management (antipsychotics, mood stabilizers)

Reference materials: Providers are directed to practice parameters and FDA prescribing information for antipsychotics and mood stabilizers when assessing and treating aggression in children and adolescents.

Links and FDA highlights are provided in policy (see referenced resources).