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Updated Prior Authorization Expansion on Physician-administered Drugs
Act
by Jun 30, 2026
Effective date
Jul 1, 2026
Identified
Jun 26, 2026
Summary
Effective July 1, 2026, South Carolina SCDHHS is expanding prior authorization requirements for physician-administered drugs covered under Healthy Connections Medicaid fee-for-service (FFS) plans. Billing teams must obtain prior authorization through Prime Therapeutics before administering the newly listed drugs to FFS Medicaid members, or claims will be denied.
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What to do
by Jun 30, 2026 · 5 steps
01Billing team must access the updated Procedure Codes section in the Physicians Services provider manual on the SCDHHS website to identify all newly added physician-administered drugs requiring prior authorization.
02Update billing system and encounter forms to require prior authorization submission for all newly listed drugs before administration to FFS Medicaid members.
03Configure system to route prior authorization requests to Prime Therapeutics Management via https://gatewaypa.com or (800) 424-8219.
04Train clinical and administrative staff on the new prior authorization requirement.
05Establish workflow to document and track prior authorization approvals for each drug administration.
If missed: Failure to obtain required prior authorization will result in claim denials for affected services rendered on or after July 1, 2026.
Original notice
Updated Prior Authorization Expansion on Physician-administered Drugs
scdhhs.gov · Always check the source before changing claims.
Related changes
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