Oversight of antipsychotic use in Medicaid-insured children varies by state

Key clinical point: Prescribing atypical antipsychotics to minors requires prior authorization in 31 states.

Major findings: Thirty-one states have implemented prior authorization requirements for prescribing atypical antipsychotics to Medicaid-insured youth, but only seven include youth to 18 years of age. Peer review processes are implemented in 15 states.

Data source: A review of Medicaid prior authorization policies for atypical antipsychotic prescribing to minors in all 50 states and the District of Columbia from June 2013 to August 2014.

Disclosures: The study was funded by the Food and Drug Administration. One author, Ian Schmid, reported FDA fellowship support administered by the Oak Ridge Institute for Science and Education. The authors reported no conflicts of interest.




Though 31 states now require prior authorization for prescribing atypical antipsychotic medications to Medicaid-insured youth, age limits and how the medications are regulated vary widely.

Requirements for physician peer review, an important consideration for a medication class with potentially negative cardiometabolic impact, also vary by state, Julie M. Zito, Ph.D., of the University of Maryland’s department of pharmaceutical health services research, and her associates reported in a research letter to JAMA (2015 March 3 [doi:10.1001/JAMA.2015.0763]) Dr. Zito and her colleagues noted that pediatric outpatient antipsychotic prescribing has sharply increased over the past 2 decades, and that a child on Medicaid is five times more likely to be prescribed an antipsychotic than a privately insured youth. Clear guidelines are lacking for antipsychotic prescribing, especially for the youngest patients, the study found.

Many states have instituted policies to gain greater oversight of pediatric psychotropic medication prescribing. To characterize nationwide practice, Dr. Zito and her colleagues collected information about prior authorization requirements for atypical antipsychotic prescribing for all 50 states and the District of Columbia. Information was collected by visiting webpages and supplemented by individual e-mail exchanges with state Medicaid authorities when necessary.

In all, 31 states’ Medicaid agencies had policies requiring prior authorization before atypical antipsychotics can be prescribed to Medicaid-insured children. Only seven states required prior authorization for all youth 18 and younger, while most others curtailed the requirement after ages 5, 6, or 7. A separate set of seven states had prior authorization requirements that varied by drug.

The prior authorization process also varied widely between states. Fifteen of the 31 states with prior authorization requirements had mandatory peer review by physicians – often psychiatrists – or had clinical pharmacists perform initial review with physicians available for consultation. By contrast, the other 16 states’ review processes were performed by nonphysician reviewers or were automated.

Dr. Zito and her colleagues said that the study compiled only limited data regarding each state’s policies. The authors recommended further study aimed at tracking unintended consequences of prescribing restrictions, as well as examining whether prior authorization with peer review improves quality of care. All in all, Dr. Zito said in an interview, “we need a much more comprehensive and holistic picture of this complex problem.”

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