Much attention has been focused on monitoring the prescribing of antipsychotic medications to children in foster care since the passage of the Child and Family Services Improvement and Innovation Act of 2011 (P.L.112-34). Children in state custody often have emotional and behavioral challenges as a result of maltreatment and trauma. Creating, coordinating and implementing monitoring protocols across various agencies (state child welfare, Medicaid and mental health systems) to ensure appropriate prescribing and monitoring of medication therapy requires careful planning.
Generally, each state Medicaid pharmacy program is actively monitoring the prescribing of antipsychotic drugs with edits, which are specified parameters that prompt for a review of the prescription claim before it is authorized for payment, unless restricted by state law. The majority of states report that they have expanded their antipsychotic monitoring programs to include all children. While there is no single way to create a perfect system, state DUR programs can develop and share effective strategies for building creative and collaborative methods for promoting quality care for these vulnerable individuals. To that end, we are providing various state summaries of strategic approaches they submitted in February of 2016 (PDF, 960.75 KB) to address this issue. Additionally, the FFY 2018 FFS (Section VIII, Part G, 2, c) and MCO (Section VII, Part G, 2, c) DUR Annual Reports outline current state and MCO Antipsychotic Monitoring Programs.
42 CFR Subpart K – Drug Use Review (DUR) Program and Electronic Claims Management System for Outpatient Drug Claims Section 456.700-456.725 provides the requirements for the DUR program.
Please direct all communications to the CMSDUR@cms.hhs.gov resource mailbox.
Disclaimer: Please note that the information provided on this web page does not bind or obligate the Centers for Medicare and Medicaid Services (CMS). The statements included on this web page are intended to provide information on CMS Medicaid Drug Utilization Review and do not in any way revise or modify the requirements set forth in Section 1927 of the Act, regulations or program releases.
Page last updated on November 8, 2021