CurrentUnitedHealthcarePolicy N/A

Antipsychotic medication prior authorization for children under 6 years

Prior authorization form and review criteria for antipsychotic medications prescribed to children under 6 years of age for Medicaid recipients; defines required documentation, monitoring, and approval duration (180 days). Governs new and continuation requests, metabolic and movement-disorder monitoring, and required attachments.

Policy Summary

PayerUnitedHealthcare

PolicyAntipsychotic medication prior authorization for children under 6 years

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit the most current, fully completed antipsychotic prior authorization form and attach required medical records and most recent metabolic labs for new and continuation requests.

POLICY UPDATE CHANGES

No material clinical or coverage changes — brief indicates has_material_change=false and provides standard review and monitoring requirements.

180 daysMaximum approval duration

Age <6Applicable population

Coverage Summary

This policy covers prior authorization for antipsychotic medications prescribed to Medicaid recipients under 6 years of age. It is covered with criteria and governs both new and continuation requests, specifying required documentation, monitoring, and an approval time limit. Relevant required materials and actions include submission of the completed antipsychotic prior authorization form, attachment of medical records and recent labs, and documentation of movement-disorder screening where applicable. The policy notes a maximum approval duration of 180 days.

Medical-Necessity Criteria

General Review Requirements

Requests will be reviewed when ALL of the following are provided:

Completed form: Most current antipsychotic prior authorization request form is submitted (form must be completed in full).
Form sections complete: All relevant sections of the antipsychotic prior authorization form are complete.
Document target symptoms: Evaluation and progress notes document target symptoms and behaviors.
Attach medical records and labs: Copies of medical records (diagnostic evaluations, recent chart notes) and most recent related labs are attached; provider must retain documentation for five years.
Movement-disorder monitoring for continuation: For continuation requests: documentation demonstrating monitoring for movement disorders is attached (e.g., AIMS or DISCUS).
Metabolic labs for continuation: For continuation requests: most recent metabolic monitoring labs (fasting glucose and fasting lipids) are attached.

Baseline and Ongoing Monitoring Requirements

Prescribers must perform and document the following ALL of the timepoints:

Monitoring schedule

Baseline measures obtained prior to starting antipsychotic: weight, height, BMI, blood pressure, fasting glucose, fasting lipids.
3-month and annual assessments: Assessments repeated at 3 months and at least annually to monitor safety and efficacy.
6-month metabolic monitoring: Fasting glucose and fasting lipids may need assessment every 6 months in young children (attach most recent labs).
Movement-disorder assessment timing: Assessment for movement disorders performed during initial titration, at 3 months, and annually (AIMS or DISCUS).

Clinical Management Expectations

Prescribing expectations (guiding principles):

Clinical management expectations

Psychosocial first: Psychosocial treatments should precede use of psychotherapeutic medications and should continue if medications are prescribed.
Risk–benefit consideration: Risks and benefits should be carefully considered before prescribing an antipsychotic.

Approval Duration

Maximum approval duration is 180 days.180 days

Provider Actions & Submission Requirements

Prior Authorization

Submit completed antipsychotic prior authorization form

The most current, fully completed antipsychotic prior authorization request form is required for all new and continuation requests. The form must be completed in full and submitted for review.

Documentation Required

Attach clinical records and labs

Attach copies of relevant medical records and recent labs with the PA request.

Diagnostic evaluations
Recent chart notes / evaluation and progress notes documenting target symptoms and behaviors
Most recent metabolic labs (official fasting glucose and fasting lipids) — required for continuation
Movement-disorder screening results for continuation requests (AIMS or DISCUS)

Documentation Required

Monitoring schedule

Baseline, at 3 months, and at least annual monitoring must include weight, height, BMI, blood pressure, and fasting glucose and fasting lipids. Assess for movement disorders during initial titration, at 3 months, and annually (e.g., AIMS or DISCUS).

Documentation Required

Retain documentation

Providers must retain copies of all documentation and medical records submitted for review for five years.

Billing Rule

Submission fax and PA phone

Fax the completed form or contact the Pharmacy PA Call Center for submission and questions.

Fax: 1-866-940-7328
Pharmacy PA Call Center: 1-800-310-6826

Background

Florida Medicaid guidance emphasizes that psychosocial treatments should precede psychotherapeutic medications in children under age 6 and should continue if medications are prescribed; prescribers must carefully weigh risks and benefits before initiating an antipsychotic.

Before starting an antipsychotic, baseline safety measures must be documented: weight, height, BMI, blood pressure, fasting glucose, and fasting lipids. These assessments should be repeated at three months and at least annually. In young children, fasting glucose and lipids may need assessment every six months.

Monitoring for movement disorders is required: assessments (for example using AIMS or DISCUS) should be performed during initial titration, at three months, and annually. Continuation requests must include documentation of movement-disorder monitoring and the most recent metabolic labs (fasting glucose and fasting lipids).

The policy references Florida Medicaid clinical guidelines and provides links to guidance documents on psychotropic medication use in children under 6.

Definitions

Thresholds / Key Limits

Policy Summary

PayerUnitedHealthcare

PolicyAntipsychotic medication prior authorization for children under 6 years

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit the most current, fully completed antipsychotic prior authorization form and attach required medical records and most recent metabolic labs for new and continuation requests.

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OpenPayer

Antipsychotic medication prior authorization for children under 6 years

Coverage Summary

Medical-Necessity Criteria

Provider Actions & Submission Requirements

Background

Coding

Revision History