According to the Centers for Disease Control and Prevention (CDC), more than 6 million US children 3-17 years old have been diagnosed with attention-deficit/hyperactivity disorder (ADHD), with approximately two-thirds taking ADHD medication. States vary widely in the number of children diagnosed with ADHD (from 6% to 16%), with even greater variation in medication treatment estimates (38% to 81%). Some state Medicaid programs have implemented policies to manage the use of ADHD medications and guide physicians toward best practices for ADHD treatment in children. Data from the Kaiser Family Foundation show that at least 75% of children enrolled in Medicaid in 36 states are covered by Managed Care Organizations (MCOs) rather than traditional fee-for-service plans. As a key delivery system, MCOs are a main source of ADHD policy implementation. These policies include prescription medication prior authorization requirements that restrict approvals to patients of a certain age or require additional provider involvement before approval for payment is granted.
This map examines features of prior authorization policies in the Medicaid managed care plans of five states (Georgia, Illinois, Nevada, New Jersey, and South Carolina) selected to be case studies for ADHD medication prior authorization in managed care. Features examined relate to pediatric ADHD medication treatment, including applicable ages, medication types, and criteria for approval in effect as of April 1, 2023. While other states may have relevant managed care ADHD policies, this analysis only examined the five listed states. A separate dataset that focuses on the prior authorization policies in Medicaid fee-for-service plans across all fifty states and the District of Columbia is available on LawAtlas.org (see Prior Authorization Policies for Pediatric ADHD Medication Prescriptions).
This publication was supported by the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award given to ChangeLab Solutions totaling $200,000 with 100 percent funded by CDC/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS, or the U.S. Government.
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