MAb2026063002

By July 6, 2026: Billing and pharmacy teams must implement the updated prior authorization procedures for antipsychotic medications in the MA Program. Specific actions required: (1) Update billing system to enforce prior authorization requirements for: non-preferred antipsychotics, antipsychotics exceeding quantity limits, all antipsychotics prescribed to children under 18, and therapeutic duplications (both atypical and typical antipsychotics); (2) Provide prescribers with updated clinical review guidelines emphasizing FDA-approved indications, dosing consistency with approved labeling/compendia/literature, and for pediatric cases: age-appropriate FDA approval, severe psychotic/neuro-developmental symptoms, prescriber specialist credentials (pediatric neurologist, child/adolescent psychiatrist, or child development pediatrician for under 14; general psychiatrist also acceptable for 14+), comprehensive evaluation documentation, non-pharmacologic therapy plans, and baseline metabolic monitoring (weight/BMI, blood pressure, glucose/A1c, lipid panel, AIMS for EPS); (3) Update prior authorization request templates to capture required clinical documentation; (4) Train pharmacy staff to route pediatric antipsychotic requests to appropriate specialists; (5) Update quantity limit enforcement rules per the PDL and quantity limits resources provided. Consequences: Claims for non-compliant prior authorization requests will be denied. For pediatric cases lacking required specialist involvement or baseline monitoring documentation, prior authorization will be rejected.