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Medicaid to implement clinical edit for ADHD/ADD stimulants

The Mississippi Drug Utilization Review Board (DUR) has recommended that the Mississippi Division of Medicaid (DOM) implement prescribing guidelines for stimulant drugs most commonly used to treat attention deficit hyperactivity disorder (ADHD)/attention deficit disorder (ADD). In accordance with the DUR Board’s March 1, 2018, recommendations DOM will implement diagnosis edits concerning the use of stimulant drugs for both adults and children. Recent analysis of Medicaid claims indicated approximately 20 percent of children prescribed stimulants did not have a Federal Drug Administration (FDA)-approved or compendia-supported indication for that product present in medical claims.

Effective Oct. 1, 2018, DOM will implement an electronic prior authorization clinical edit. The edit requires the presence of at least one FDA-approved indication or compendia-supported indication for each stimulant product prescribed. A list of FDA-approved or compendia-supported indications covered by DOM, along with corresponding ICD-10 codes, can be found on DOM’s Pharmacy Resource website page.

In order for a prescription claim to be electronically approved, the diagnosis must either be:

  • Present in the patient’s medical paid claims history within the past 24 months of the prescription fill, or
  • Written on the prescription by the prescriber and submitted by the pharmacist on the prescription claim.

Providers should be aware the new clinical edit is being implemented and taking effect Oct. 1, 2018, so that they may plan appropriately for uninterrupted care of their patients. For questions or more information, please contact the Office of Pharmacy at 601-359-5253, Option 4.