Pharmacy Behavioral Health Clinical Edits

[Reprinted from the June 2017 Medicaid Pharmacy Newsletter]

On May 1, 2017, new pharmacy point of sale (POS) clinical edits for behavioral health medications became effective for pediatric and adult beneficiaries prescribed such medications. These edits are specifically related to dosage and quantity prescribed which exceeds the Food and Drug Administration (FDA) approved maximum dosage, dosage schedule and in class therapeutic duplication.

A 90-day grace period is in place to allow providers and pharmacists an opportunity to identify and address any therapeutic issues that may be impacted by these new POS behavioral health clinical edits. Pharmacists are encouraged to contact prescribers if they identify any beneficiary that may be affected.  The edits will deny pharmacy claims beginning on July 30, 2017.    Bypassing the edit will require an override that should be used by the pharmacist when the prescriber provides clinical rationale for the therapy issue identified by the edit.  The edit override is 10 entered in a submission clarification code field.    

The edit descriptions for pediatrics and adults follow:

Note:  Concomitant use is 60 or more days of overlapping therapy.

  • Quantities more than the dosages recommended by the FDA for the atypical antipsychotics
  • Quantities more than the dosages recommended by the FDA for the antidepressants
  • Quantities more than the dosages recommended by the FDA for attention deficit/attention deficit hyperactivity disorder (ADD/ADHD) medications
  • Concomitant use of three or more atypical antipsychotics
  • Concomitant use of two or more antidepressants (Selective serotonin reuptake inhibitor -SSRIs)
  • Concomitant use of two or more antidepressants (Serotonin–norepinephrine reuptake inhibitor - SNRIs)
  • Concomitant use of two or more anxiolytics
  • Quantities more than the dosages recommended by the FDA for the behavioral health medications (does not include antidepressants, atypical antipsychotics, stimulants and ADD/ADHD medications)