Objective To describe the children with persistent asthma receiving non-preferred controller therapy in the form of leukotriene receptor antagonist monotherapy (LTRAM). Study design In this cross-sectional study, we analyzed 2007-2009 South Carolina Medicaid data of children aged 2- to 18 years with persistent asthma, defined by Healthcare Effectiveness Data and Information Set (HEDIS). Those without either LTRAM or inhaled corticosteroids (ICS) were excluded. With multivariable logistic regression modeling, we compared the outcome of LTRAM with the primary predictor of age and adjusted for covariates of race, sex, HEDIS class, rurality, and disease severity. We also used negative binomial regression to compare outcomes of albuterol and oral steroid claims, outpatient and emergency department visits, and hospitalizations with predictors of LTRAM vs ICS therapy. Results A total of 19 512 patients with asthma aged 2- to 18-years were studied: 2658 (13.6%) without controllers were excluded, 2508 (12.9%) received LTRAM, and 14 346 (73.5%) received ICS. Age, race, rurality, and HEDIS classification were all significantly associated with LTRAM (all P <.01): 5- to 13-year-olds relative to children <5 years old (OR 1.46, 95% CI 1.30-1.64), Caucasians relative to African Americans (OR 1.40, 95% CI 1.27-1.53), and rural children relative to urban (OR 1.18, 95% CI 1.08-1.3) were all more likely to receive LTRAM. Albuterol, oral steroid, and outpatient visits were lower in LTRAM (P <.01). No difference was detected in emergency department visits or admissions. Conclusions Children 5- to 13-years of age, rural children, and Caucasian children were more likely to receive LTRAM. Uncovering provider rationale and practices as well as patient influences on this prescribing pattern may be helpful in optimizing asthma controller therapy. © 2014 Mosby Inc. All rights reserved.