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Pediatric Antipsychotic Utilization Program (Revised)
Act
by Apr 15, 2026
Effective date
Apr 15, 2026
Identified
Jun 25, 2026
Summary
Humana has revised its Pediatric Antipsychotic Utilization Program (effective April 15, 2026) establishing stricter prior authorization requirements for all antipsychotic medications in pediatric patients aged <6 years (requires compendia-supported diagnosis) and ≥6 years (standard coverage), plus new restrictions on concurrent antipsychotic use in patients ≥6 years. This policy applies to Florida, South Carolina, Oklahoma, and Virginia Medicaid plans and affects 60+ antipsychotic formulations across typical and atypical classes.
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What to do
by Apr 15, 2026 · 9 steps
01Billing and prior authorization teams must implement the following changes for Medicaid plans in FL, SC, OK, and VA.
02Configure 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.
03For patients <6 years of age, flag requests requiring compendia-supported diagnosis documentation before authorization approval.
04For patients ≥6 years with concurrent antipsychotic use, require prior authorization and verify compendia-supported diagnosis for multiple concurrent therapy.
05Update encounter forms and clinical decision support to alert prescribers and staff of these age-based restrictions.
06Train billing staff and prior auth reviewers on the age thresholds (pediatric <12 years, adolescent 13-17 years) and compendia requirements.
07Update provider-facing materials to explain authorization workflows.
08Claims submitted without required prior authorization for these populations will be denied.
09Verify coverage under each state's Medicaid plan rules, as policy applies only to FL, SC, OK, and VA Medicaid lines of business.
Original notice
Pediatric Antipsychotic Utilization Program (Revised)
mcp.humana.com · Always check the source before changing claims.