1. 1 ADHD and AAP Drug Safety Standards for Medicaid Children Health and Recovery Services Administration (HRSA) Dr. Jeffrey Thompson, Medical Director Fee-for-Service (FFS) Pharmacy Program

2. 2 Background  Evidence-based medicine WAC 388-501-0165 defines how to grade and apply evidence to make coverage decisions.  ADHD and AAP drug reviews were performed by evidence- based practice centers OHSU, RAND, and CADIE.  The Mental Health Community experts join with HRSA in examining the studies and recommending ADHD and AAP safety edits for Fee-for-Service (FFS) Medicaid Children.  The Mental Health Drugs Work Group (MHDW) reviews evidence and examines current utilization practices within the Children’s Medicaid FFS population.  The MHDW partners with community experts and HRSA to assess evidence and utilization for appropriate use of ADHD and AAP drugs for children.

3. 3 Some key Questions When Making Coverage and Safety Decisions What is the quality of the research justifying the request? What is the estimation of harm if the treatment was to occur? What is the equally effective lower cost alternative? Is there a vulnerable population that perhaps requires higher levels of evidence?  or IRB approval/informed consent?

4. 4 Community ADHD Drug Prescribing Practices for Medicaid FFS Children Age 17 and under FY2005

5. 5 Community AAP Drug Prescribing Practices for Medicaid FFS Children < 3 yrs.#Clients# ABOVE RECOMMENDED DOSE Total11 ABILIFY CLOZAPINE GEODON RISPERDAL11 SEROQUEL ZPREXA 3–5 Yrs.# clients# ABOVE RECOMMENDED DOSE Total12940 ABILIFY12 CLOZAPINE-0- GEODON22 RISPERDAL9911 SEROQUEL11 ZPREXA54

6. 6 Community AAP Drug Prescribing Practices for Medicaid FFS Children 6 - 12 YRS#clients# ABOVE RECOMMENDED DOSE Total2657288 ABILIFY52157 CLOZAPINE-0- GEODON7925 RISPERDAL137338 SEROQUEL516132 ZPREXA16836 13 - 17 YRS# clients# ABOVE RECOMMENDED DOSE Total310890 ABILIFY73415 CLOZAPINE4-0- GEODON2149 RISPERDAL108415 SEROQUEL82643 ZPREXA2468

7. 7 Mental Health Drug Work Group Agrees on Safety Edits for ADHD and AAP  For endorsing and non-endorsing providers 1. Age limits 2. Dose limits 3. Combination limits 4. Sedatives 5. Second Opinion opportunities  For non-endorsing providers 1. Tried and failed two preferred, or 2. Some documentation of intolerance to starting with a preferred drug

8. 8 Children’s ADHD Safety Edits ADHD MedicationsMaximum Dose Client Numbers % of Total User Population Methylphenidates >5 Years of Age> 120 mg 2961.8% 3-5 Years of Age> 30 mg4152.6% < 3 Years of AgeN/A47<1% Amphetamine >5 Years of Age> 60 mg1131% 3-5 Years of Age> l5 mg3302% < 3 Years of AgeN/A30<1%

9. 9 Mental Health Drug Work Group Safety Recommendation for APP

10. 10 Outcomes What are the Objectives  Improve Mental Health Therapy  Define Mental Health Therapies  Measure Mental Health Therapy by Reviewing: Number of Rx’s Assessments Cognitive behavior Poly-pharmacy Poly-prescriber’s Adherence Coordination of care

11. 11 Questions