Pediatric Antipsychotic Utilization Program (Revised)

By April 15, 2026: Billing and prior authorization teams must implement the following changes for Medicaid plans in FL, SC, OK, and VA: (1) Configure billing system to require prior authorization for ALL antipsychotic medications (both first-generation and second-generation agents listed in the policy) for pediatric and adolescent patients; (2) For patients <6 years of age, flag requests requiring compendia-supported diagnosis documentation before authorization approval; (3) For patients ≥6 years with concurrent antipsychotic use, require prior authorization and verify compendia-supported diagnosis for multiple concurrent therapy; (4) Update encounter forms and clinical decision support to alert prescribers and staff of these age-based restrictions; (5) Train billing staff and prior auth reviewers on the age thresholds (pediatric <12 years, adolescent 13-17 years) and compendia requirements. Update provider-facing materials to explain authorization workflows. Claims submitted without required prior authorization for these populations will be denied. Verify coverage under each state's Medicaid plan rules, as policy applies only to FL, SC, OK, and VA Medicaid lines of business.