MedicaidPrior AuthHigh impact
Updated Prior Authorization Expansion on Physician-administered Drugs
SC Medicaid - SCDHHS·SC·Prior Authorization
Effective date
Jul 1, 2026
We identified it
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.
Action Required
By June 30, 2026: (1) Billing 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. (2) Update billing system and encounter forms to require prior authorization submission for all newly listed drugs before administration to FFS Medicaid members. (3) Configure system to route prior authorization requests to Prime Therapeutics Management via https://gatewaypa.com or (800) 424-8219. (4) Train clinical and administrative staff on the new prior authorization requirement. (5) Establish workflow to document and track prior authorization approvals for each drug administration. Failure to obtain required prior authorization will result in claim denials for affected services rendered on or after July 1, 2026.