Medication Management and Other Prescriber Services

​​​​​​​For full service definition information link here to the Clinical Coverage Policy.

Medication management is an essential aspect of the mental health continuum of care, specifically for those with moderate to severe mental illness and/or SPMI diagnoses. Medications are first line treatments for many disorders ranging from ADHD to schizophrenia. Practicing best practice medication management is increasingly important, especially given the increasing array of medication options, the routine use of off-label prescribing, frequency of prescribing controlled substances to those with co-morbid substance abuse, polypharmacy, and the frequent use of brand name medications when equivalent generic options are available.

For those receiving psychotropic medication management, the Physician/Prescriber is ultimately responsible for ensuring appropriate care is coordinated for the individuals he or she serves. Prescribers (psychiatrists, other physicians, nurse practitioners (NP), and physician assistants) are expected to direct the care provided by the entire behavioral health team, even when services are provided by those who do not directly work for the prescriber or the prescriber's agency. Ultimately, the prescriber is responsible for ensuring medically necessary care is being provided across the service array for any given member under his/her care.​

Intended Population

  • Any member where Clinical Practice Guidelines recommend medication intervention to treat their behavioral health condition

  • Generally those with Severe Mental Illness (SMI) and Serious and Persistent Mental Illness (SPMI), as well as children who are Seriously Emotionally Disturbed (SED) should be treated by a psychiatric specialty provider (psychiatrist, child and adolescent psychiatrist, or psychiatric NP), whereas those with mild to moderate illnesses can be managed by either a behavioral health prescriber or a primary care provider. For those with access to primary care and who have mild illnesses, medication management, if indicated, should be provided in the primary care setting due to limited psychiatric prescriber resources.

  • Those who would benefit from an opioid treatment program should be seen in that setting, and those who would benefit from Suboxone treatment should accordingly see a specialist.

  • Those with the most severe illnesses, treatment resistance, and/or significant medical or psychiatric co-morbidities should be treated by the most advanced providers (ABPN certified MD or DO).

Recommended Best Practices​

  • Core Best Practices

  • Specifically, follow evidenced based Clinical Practice Guidelines that:

    • Minimize off-label prescribing and recognizing off-label prescribing for youth is often the rule rather than the exception

    • Minimize unjustified polypharmacy

    • Minimize the prescribing of controlled substances without clear clinical justification, especially in those with co-morbid substance abuse

    • Minimize the use of psychotropic medications where no evidence-base exists

    • Maximize the use of generic psychotropic medications when clinically indicated, while minimizing the use of brand name psychotropics when equivalently effective generic options are available and tolerable by the member

  • For patients with high behavioral health needs, medical care may be best coordinated by the behavioral health prescriber, even when medical needs are also high.

  • Consultation with North Carolina's Controlled Substances Registry for those on controlled substances (see CCNC's Chronic Pain Tool Kit) at the point of initial evaluation and at each episode of prescribing. Moreover, there is no evidence supporting daily use of benzodiazepines for longer than 30-60 days (see adopted Benzodiazepine guideline)

  • Physicians should regularly measure body mass index (BMI), fasting glucose or Hgb A1C, blood pressure and a fasting lipid panel for those on atypical antipsychotic medications

  • ​Regular measurement of the Antipsychotic Involuntary Movement Scale (AIMS) for all patients on antipsychotic medications

  • Smoking cessation counseling

Desired Outcomes​

  • Core Expected Outcomes

  • Improve coordination of physical health care, including physical health screenings and preventative care, by behavioral health prescribers when a member has high behavioral health needs.

Management Approach

  • Core Management Strategies

  • Authorization Guidelines​​

  • Cardinal Innovations does not have pre-established restrictions for access to behavioral health prescriber services. Generally, access to psychiatric care is encouraged for overall improvement in quality of care.  For adults, Medicaid restricts the number of Evaluation and Management (E&M) services per year per patient to 22, though these services are unlimited for those with schizophrenia, depression and bipolar spectrum disorders.

  • Diagnosis-specific Clinical Practice Guidelines are adopted as recommended by our Clinical Advisory Committee, and utilization reviews of patient charts should demonstrate fidelity to these guidelines or should find clear explanations for deviations from these guidelines.

  • Conduct focused utilization review of prescribers based upon over/under utilization, poor outcomes such as high inpatient or crisis system usage, critical incidents or grievances, data suggesting a prescriber's practices are an outlier compared to the community standard of care (e.g., for polypharmacy, use of controlled substances, off-label usage).

  • Provision of training about prescriber leadership in collaboration with the UNC Center of Excellence in Community Mental Health.

  • Monitoring of Comprehensive Community Clinic (CCC) prescribers' completion of indicated metabolic syndrome screening, smoking cessation counseling, and AIMS performance on a yearly basis.

  • CPT codes, 99-codes, explanations.