Medication Review

Provider Requirements and Service Limitations

From The July 2007 Florida Medicaid Provider Handbook

Medication Review- Requirements To Receive


Medication review is an independent review and assessment of all prescription and
over-the-counter medications taken by a recipient. The purpose of the drug regimen
review is to assess, among other clinical considerations, whether drug therapy is
needed, accurate, valid, non-duplicative and correct for the indication (diagnosis); that
therapeutic doses and administration are at an optimum level; that there is appropriate
monitoring (laboratory or clinical testing); and that drug interactions, allergies and
contraindications are assessed and prevented.

This service is provided by consultant pharmacists to recipients who meet any of the following criteria and is medically indicated:
Have a prescription for and are receiving or will be receiving within the next 30
days any psychotropic medication including atypical antipsychotics such as
Risperdal (Risperidone), Zyprexa (Olanzapine), Clozaril (Clozapine), Seroquel
(Quetiapine), or Gedone (Ziprasidone);
Have a prescription for and are receiving or will be receiving within the next 30
days any medication associated with tardive dyskinesia;
Have a prescription for and are receiving or will be receiving within the next 30
days any of the following medications: Digoxin (Lanoxin), Lithium,
Carbamazepine (Tegretol), Phenytoin (Dilantin), Valproic Acid/Valproate
(Depakene/Depakote), Primidone (Mysoline, Phenobarbital, or Theophylline);
Have a prescription for and are receiving or will be receiving within the next 30
days any neuroleptic medication;
Have a seizure disorder which: (a) is not controlled by medication as evidenced by
documentation of seizure activity within the last twelve months or (b) requires the
use of 2 or more anti-epileptic drugs (AED’s);
Receive routine monitoring for any of the following: potassium, sugar, thyroid and
drug levels;
Have a chronic disease associated with the blood, brain, lungs, heart, liver,
skin, kidney and circulation, including diabetes;
Have been hospitalized or visited the emergency room in the past 18 months
for a medication-related problem; and
Have a prescription for and are taking two or more anti-epileptic medications
or is taking one anti-epileptic medication and any other medication.


Medication review services are limited to two reviews per year unless the
prescribing physician writes an order and determines it is medically necessary for
additional reviews based on the criteria provided above.

Documentation Requirements
Reimbursement* and monitoring documentation to be maintained by the provider:
1. *Copy of claims submitted for payment; and
2. *Report summarizing the medication review.
Such review shall contain recommendations for changes in medications and shall
also be provided by the consultant pharmacist to the recipient, family or legal
guardian, and the prescribing physician.
Follow-up by the consultant pharmacist with the prescribing physician shall be
provided. The consultant pharmacist will provide written guidelines and
information for use by the recipient and his caregivers about medication
administration and other interventions specific to the recipient’s needs designed to
improve the therapeutic outcome of currently prescribed medications. For
monitoring purposes, the provider must have all of the above-mentioned
documents available.
Documentation to be submitted to the waiver support coordinator by the provider:
1. Copy of claim submitted for payment; and
2. Copy of report summarizing the medication review prior to or at the time of
claim submission.
Note: *Indicates reimbursement documentation.
Place of Service This service is performed at the recipient’s place of residence or the provider’s

Medication Review Provider Requirements

Medication Review Provider Requirements
Provider Qualifications Medication review providers shall be consultant pharmacists licensed in
accordance with Chapter 465, F.S.