Information For Dates of Service Before October 1, 2015

Pharmacy Responsibilities for Antipsychotic Drugs for Children 7 Years of Age and Younger

Pharmacy providers should ensure that they have received the completed Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 7 Years of Age and Younger from the prescriber.

Pharmacy providers should determine the ForwardHealth benefit plan in which the member is enrolled. After the benefit plan is confirmed, pharmacy providers should review the program-specific covered drug or product list.

For Standard Plan and Medicaid members, pharmacy providers should review the Preferred Drug List Quick Reference for the most current list of preferred and non-preferred drugs.

If a Standard Plan or Medicaid member presents a prescription for a non-preferred antipsychotic drug, the pharmacy provider is encouraged to contact the prescriber to discuss preferred drug options. The prescriber may choose to change the prescription to a preferred antipsychotic drug, if medically appropriate for the member.

It is important that pharmacy providers work with prescribers to ensure that members are given appropriate assistance regarding coverage information and the PA request submission process for antipsychotic drugs. Pharmacy providers are responsible for the submission of the Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 7 Years of Age and Younger to ForwardHealth. Pharmacy providers are required to retain a completed and signed copy of the PA form.

Brand name antipsychotic drugs prescribed to children 7 years of age and younger that are brand medically necessary require a PA Drug Attachment for Antipsychotic Drugs for Children 7 Years of Age and Younger to be submitted on the ForwardHealth Portal, by fax, or by mail with the PA/BMNA and the PA/RF.

Two unique PA numbers will be assigned for a brand medically necessary antipsychotic drug. One PA number will be assigned to the Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 7 Years of Age and Younger and the other will be assigned to the PA/BMNA.

Prior Authorization Request Submission Methods

Pharmacy providers are encouraged to use the STAT-PA system to submit antipsychotic PA requests for members diagnosed with one of the following conditions:

PA requests cannot be submitted using the STAT-PA system if at least one of the following is true:

If the PA is not approved through the STAT-PA system, pharmacy providers are required to submit the Prior Authorization Drug Attachment for Antipsychotic Drugs for Children 7 Years of Age and Younger form, and a PA/RF, and any supporting documentation from the prescriber via the FowardHealth Portal, by fax, or by mail.