Examination of prior authorization policies for antipsychotic prescribing to children

Over the past two decades, antipsychotic prescribing to youth, almost exclusively comprising atypical antipsychotic medications, was estimated to have increased from 0.16 percent in 1993- 1998 to 1.07 percent in 2005-2009 in office-based physician visits. Antipsychotic use is also 5-fold greater in Medicaid-insured youth than in privately insured youth, and occurs mostly for indications not approved by the U.S. Food and Drug Administration (FDA). In light of antipsychotic treatment-emergent cardiometabolic adverse events, several government reports called for efforts to improve pediatric psychotropic medication oversight in state Medicaid agencies. Such efforts have included age­restricted prior authorization policies, which require clinicians to obtain preapproval from Medicaid agencies to prescribe atypical antipsychotics to children younger than a certain age as a condition for coverage, according to background information in the article.

Julie M. Zito, Ph.D., of the University of Maryland, Baltimore, and colleagues reviewed antipsychotic-related Medicaid prior authorization policies for youth (<18 years) in 50 states plus the District of Columbia between June 2013 and August 2014 and characterized these policies according to age­restriction criteria and whether a peer review process was present. A subset of prior authorization policies, classified as "peer review," brings clinical expertise into the review process by requiring contracted clinicians (peer reviewers) to adjudicate antipsychotic prescriptions for children.

The researchers found that 31 states have implemented prior authorization policies for atypical antipsychotic prescribing to children, mostly within the past 5 years. Most states apply their policies to children younger than 5, 6, or 7 years of age. Only 7 states (Alabama, Kentucky, Maryland, Nevada, North Carolina, Pennsylvania, Tennessee) apply their policies to Medicaid-insured youth up to age 18 years. Seven other states (California, Colorado, Georgia, Mississippi, Nebraska, New York, Washington) have age-restriction criteria that vary by drug entity.

Of the 31 states, 15 have incorporated a peer review process, wherein the adjudication process usually involves a psychiatrist or other physician specialty. The programs without a peer review process use automated systems or non­physician manual reviews for adjudication.

"The findings may inform pediatric research to assess the effect of these policies on atypical antipsychotic use to ensure clinical appropriateness and to minimize unintended consequences," the authors write.

They add that potential unintended consequences of these restrictive policies include inadequate treatment, substitution of potentially inappropriate, off-label psychotropic medication classes such as anticonvulsant mood stabilizers and antidepressants, and administrative burden on prescribers.

"Additionally, Medicaid oversight programs should be concerned not only with unnecessary antipsychotic use, but also should ensure adherence to appropriate cardiometabolic monitoring practices at baseline and during antipsychotic treatment, and support access to alternative evidence-based nonpharmacological treatments."