Fillable Pa 64 Form Pediatric Behaviorial Health Medication Initiative Rev 05 17 Fill (Commonwealth of Massachusetts)

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Pa 64 Form Pediatric Behaviorial Health Medication Initiative Rev 05 17 Fill (Commonwealth of Massachusetts)

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Commonwealth of Massachusetts
MassHealth Drug Utilization Review Program
P.O. Box 2586, Worcester, MA 01613-2586
Fax: 1-877-208-7428 Phone: 1-800-745-7318
Pediatric Behavioral Health Medication Initiative
Prior Authorization Request
MassHealth reviews requests for prior authorization (PA) on the basis of medical necessity only. If
MassHealth approves the request, payment is still subject to all general conditions of MassHealth, including
current member eligibility, other insurance, and program restrictions. MassHealth will notify the requesting
provider and member of its decision. Keep a copy of this form for your records. If faxing this form, please use
black ink.
The Pediatric Behavioral Health Medication Initiative requires prior authorization for pediatric members
(generally members < 18 years of age) for certain behavioral health medication classes and/or specific medication
combinations (i.e. polypharmacy) that have limited evidence for safety and efficacy in the pediatric population. For
a comprehensive medication list and additional information about the Pediatric Behavioral Health Medication
Initiative, including PA requirements and preferred products please refer to the MassHealth Drug List at
www.mass.gov/druglist.
Member information
Last name ______________________________ First name ___________________________ MI ___________
MassHealth member ID # __________________ Date of birth ________________________________________
Gender (Check one.) F M Member’s place of residence home nursing facility
Medication information
Section I. Please complete for all requests for medications subject to the Pediatric Behavioral Health
Medication Initiative for members < 18 years of age.
Is the member currently in an acute care setting?
Yes. (Inpatient) Yes. (Community Based Acute Treatment)
Yes. (Partial Hospitalization) No.
For members who are in an acute care setting, please document the outpatient prescriber after discharge.
Prescriber name __________________________________ Contact information ______________________
Has the member been hospitalized for a psychiatric condition within the past three months?
Yes. Please document dates of hospitalization within the past three months. __________ No.
On the current regimen, is the member considered to be a severe risk of harm to self or others?
Yes. Please provide details. _________________________________________________ No.
For regimens including an antipsychotic, are appropriate safety screenings and monitoring being conducted (e.g.
weight, metabolic, movement disorder, cardiovascular, and prolactin-related effects)?
Yes. No. Please explain. _____________________________________________________________
Has informed consent from a parent or legal guardian been obtained?* Yes. No.
Please indicate prescriber specialty below.
Psychiatry Neurology Other ________________________________________________________
Specialist consult details (if the prescriber submitting the request is not a specialist)
____________________________________________________________________________________
Name(s) of the specialist(s)
______________________ Date(s) of last visit or consult _______________
Contact information ____________________________________________________________________
PA-64 (Rev. 05/17) over
Print
Clear
For mid-level practitioners (e.g., nurse practitioners, physician assistants), please provide the name and specialty
of the collaborating physician.
__________________________________________________________________________________________
Please document member custody status.
Parent/Guardian Department of Children and Families (DCF)
Please document member placement status.
Home with Parent/Guardian Foster Care Residential Treatment Facility
Uncertain Other _____________________________________________________________________
Please document agency involvement.
DCF Department of Mental Health (DMH)
Department of Developmental Services (DDS) Department of Youth Services (DYS)
Is the member/family currently receiving appropriate psychotherapeutic and/or community based services for the
targeted clinical mental health related concerns (e.g., Applied Behavioral Analysis, Children’s Behavioral Health
Initiative, school interventions, specialized placement)?
Yes. Please document details of interventions below, if applicable. No.
_______________________________________________________________________________________
_______________________________________________________________________________________
Psychiatric care provided is coordinated with other psychotherapeutic and community based services. Yes. No.
Is this member a referral candidate for care coordination? Yes. No.
If yes, MassHealth will offer this member care coordination services. Please describe which additional
behavioral health services would be beneficial.
_______________________________________________________________________________________
_______________________________________________________________________________________
*
Sample informed consent form available on the MassHealth PBHMI Information webpage. For additional information go
to: http://www.mass.gov/eohhs/provider/insurance/masshealth/pharmacy/pbhm-information.html
Section II. Polypharmacy within the same medication class (e.g., antidepressants, benzodiazepines,
cerebral stimulants, mood stabilizers). Complete this section for all members < 18 years of
age if request will result in polypharmacy within the same medication class.
Please document complete treatment plan for the agents requested from the same medication class.
1. Medication name/dose/frequency __________________________ Indication ________________________
2. Medication name/dose/frequency __________________________ Indication ________________________
3. Medication name/dose/frequency __________________________ Indication ________________________
4. Medication name/dose/frequency __________________________ Indication ________________________
5. Other(s) ________________________________________________________________________________
Please document if monotherapy trials (include drug name, dates/duration of use, and outcome) were tried
before prescribing polypharmacy with two or more agents within the same medication class for this member.**
__________________________________________________________________________________________
__________________________________________________________________________________________
Please document clinical rationale for polypharmacy within the same medication class for this member.
__________________________________________________________________________________________
__________________________________________________________________________________________
Please document the treatment plans for medication regimen simplification (e.g., dose consolidation, frequency
reduction) or medical necessity for continuation of a complex medication regimen.
__________________________________________________________________________________________
__________________________________________________________________________________________
**Attach a letter with additional information regarding medication trials as applicable.
over
Section III. Antipsychotic Polypharmacy. Complete this section for all members < 18 years of age if
request will result in prescription of two or more antipsychotics for ≥ 60 days within a 90 day
period.
Please document complete treatment plan (include all antipsychotic agents [first-generation and/or second-
generation]).
1. Antipsychotic name/dose/frequency _________________________ Indication ________________________
2. Antipsychotic name/dose/frequency _________________________ Indication ________________________
3. Antipsychotic name/dose/frequency _________________________ Indication ________________________
4. Other(s) ________________________________________________________________________________
Please select the stage of treatment and clinical rationale for antipsychotic polypharmacy.
Acute stage (initiation of antipsychotic treatment likely with subsequent dose adjustments to maximize
response and minimize side effects)
Member experienced an inadequate response or adverse reaction to two monotherapy trials with
antipsychotics.
Drug name 1 ___________________________________ Dates/Duration of use ____________________
Drug name 2 ___________________________________ Dates/Duration of use ____________________
Member is transitioning from one antipsychotic to the other.
Other, please explain. ________________________________________________________________
Maintenance stage (response to antipsychotic treatment with goal of remission or recovery)
1. Is the regimen effective, therapy benefits outweigh risks, and appropriate monitoring is in place?
Yes No
2. Has the member been on the requested regimen for ≥ 12 months?
Yes. Please document clinical rationale for extended therapy.
Previous efforts to reduce/simplify the antipsychotic regimen in the past 24 months resulted in
symptom exacerbation.
Family/caregiver does not support the antipsychotic regimen change at this time due to risk of
exacerbation.
Other significant barrier for antipsychotic therapy discontinuation. Please explain.
__________________________________________________________________________________
No.
Discontinuation stage (clinically indicated that the antipsychotic regimen can likely be successfully
tapered)
Member is transitioning from one antipsychotic to the other.
Member is tapering antipsychotic. Please describe taper plan including duration. _________________
____________________________________________________________________________________
Section IV. Behavioral Health Medication (e.g., antidepressant, atomoxetine, benzodiazepine,
buspirone, or mood stabilizer) for members < six years of age.
Please document complete treatment plan (medication name/dose/frequency/duration and indication) for the
requested behavioral health medication(s).
__________________________________________________________________________________________
__________________________________________________________________________________________
Please document any previous medication trial(s). Include drug name, dates/duration of use, and outcome.**
__________________________________________________________________________________________
__________________________________________________________________________________________
Please document clinical rationale for use of an antidepressant, atomoxetine, benzodiazepine, buspirone, or
mood stabilizer for this member < six years of age.
__________________________________________________________________________________________
__________________________________________________________________________________________
**Attach a letter with additional information regarding medication trials as applicable. over
Section V. Antipsychotic Request for Members < six years of age.
Please document complete treatment plan (include all antipsychotic agents [first-generation and/or second-
generation] with dose/frequency/duration and indication(s) for the requested medication(s)).
__________________________________________________________________________________________
__________________________________________________________________________________________
Please select the stage of treatment and clinical rationale for use of an antipsychotic for this member < six years
of age.
Acute stage (initiation of antipsychotic treatment likely with subsequent dose adjustments to maximize
response and minimize side effects)
Maintenance stage (response to antipsychotic treatment with goal of remission or recovery)
1. Is the regimen effective, therapy benefits outweigh risks, and appropriate monitoring is in place?
Yes No
2. Has the member been on the requested regimen for ≥ 12 months?
Yes. Please document clinical rationale for extended therapy.
Previous efforts to reduce/simplify the antipsychotic regimen in the past 12 months resulted in
symptom exacerbation.
Family/caregiver does not support the antipsychotic regimen change at this time due to risk of
exacerbation.
Other significant barrier for antipsychotic therapy discontinuation. Please explain.
No.
Discontinuation stage (clinically indicated that the antipsychotic regimen can likely be successfully
tapered)
Member is transitioning from one antipsychotic to the other.
Member is tapering antipsychotic. Please describe taper plan including duration.
____________________________________________________________________________________
____________________________________________________________________________________
Section VI. Alpha
2
Agonist or Cerebral Stimulant Request for Members < three years of age.
Please document complete treatment plan (medication name/dose/frequency/duration and indication) for the
requested alpha
2
agonist and/or cerebral stimulant medication(s).
__________________________________________________________________________________________
__________________________________________________________________________________________
Please document any previous medication trial(s). Include drug name, dates/duration of use, and outcome.**
__________________________________________________________________________________________
__________________________________________________________________________________________
Please document clinical rationale for use of an alpha2 agonist and/or cerebral stimulant for this member < three
years of age.
__________________________________________________________________________________________
__________________________________________________________________________________________
**Attach a letter with additional information regarding medication trials as applicable.
over
Section VII. Hypnotic Request for Members < six years of age.
Please document complete treatment plan (medication name/dose/frequency/duration and indication) for the
requested hypnotic medication(s).
__________________________________________________________________________________________
__________________________________________________________________________________________
Please document if member has other behavioral health comorbidities (e.g., anxiety, depression, ADHD).
__________________________________________________________________________________________
__________________________________________________________________________________________
Please document medication trials with melatonin and/or clonidine, if clinically appropriate. Include drug name,
dates/duration of use, and outcome.**
__________________________________________________________________________________________
__________________________________________________________________________________________
Please document clinical rationale for the use of a hypnotic agent for this member < six years of age.
__________________________________________________________________________________________
__________________________________________________________________________________________
**Attach a letter with additional information regarding medication trials as applicable.
Section VIII. Multiple Behavioral Health Medications. Complete this section for all members < 18 years of
age if request will result in prescriptions of four or more behavioral health medications within
a 45 day period. For a complete list of all behavioral health medications, please refer to the
MassHealth Pediatric Behavioral Health Medication Initiative.
Please document complete treatment plan (include all behavioral health agents and indication(s) for each
medication(s)).
1. Medication name/dose/frequency ___________________________ Indication ________________________
2. Medication name/dose/frequency ___________________________ Indication ________________________
3. Medication name/dose/frequency ___________________________ Indication ________________________
4. Medication name/dose/frequency ___________________________ Indication ________________________
5. Medication name/dose/frequency ___________________________ Indication ________________________
6. Medication name/dose/frequency ___________________________ Indication ________________________
7. Other(s) _________________________________________________________________________________
Please document monotherapy trials (include drug name, dates/duration of use, and outcome) tried before
prescribing a polypharmacy regimen for this member.**
__________________________________________________________________________________________
Please document clinical rationale for use of multiple behavioral health medications for this member < 18 years of
age.
__________________________________________________________________________________________
__________________________________________________________________________________________
Please document the treatment plans for medication regimen simplification (e.g., dose consolidation, frequency
reduction) or medical necessity for continuation of a complex medication regimen.
__________________________________________________________________________________________
__________________________________________________________________________________________
**Attach a letter with additional information regarding medication trials as applicable.
over
Section IX. Please complete for all requests for non-preferred drug products if one or more preferred
drug products have been designated for this class of drugs.
If one or more preferred drug products have been designated for this class of drugs, and if you are requesting PA
for a non-preferred drug product, please provide medical necessity for prescribing the non-preferred drug product
rather than the preferred drug product.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Prescriber information
Last name* _______________________________ First name* ________________________ MI ____________
NPI* ____________________________________ Individual MH Provider ID ____________________________
DEA No. _________________________________ Office Contact Name _______________________________
Address __________________________________ City ________________ State ________ Zip ____________
E-mail address _____________________________________________________________________________
Telephone No.* ____________________________ Fax No.* _________________________________________
* Required
Prescribing provider’s attestation, signature, and date
I certify under the pains and penalties of perjury that I am the prescribing provider identified in the Prescriber
information section of this form. Any attached statement on my letterhead has been reviewed and signed by me. I
certify that the medical necessity information (per 130 CMR 450.204) on this form is true, accurate, and
complete, to the best of my knowledge. I understand that I may be subject to civil penalties or criminal
prosecution for any falsification, omission, or concealment of any material fact contained herein.
Prescribing provider’s signature (Signature and date stamps, or the signature of anyone other than the provider,
are not acceptable.)
Signature required _________________________________________________________________________
Printed name of prescribing provider ______________________________ Date _________________________
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Pa 64 Form Pediatric Behaviorial Health Medication Initiative Rev 05 17 Fill (Commonwealth of Massachusetts)

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Completed 26 July 2020

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