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Updated Prior Authorization Expansion on Physician-administered Drugs
Act
by Sep 30, 2026
Effective date
Oct 1, 2026
Identified
Sep 19, 2026
Summary
Effective October 1, 2026, South Carolina SCDHHS will require prior authorization for an expanded list of physician-administered drugs when given to Healthy Connections Medicaid fee-for-service members. The specific drugs requiring PA are listed in the SCDHHS Physicians Services Provider Manual and a supplemental document. All requests for PA must be submitted to Prime Therapeutics Management.
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What to do
by Sep 30, 2026 · 2 steps
01Billing team must (1) access the updated SCDHHS Physicians Services Provider Manual and the linked list of additional physician-administered drugs requiring prior authorization; (2) identify which drugs your practice administers that are on the new PA-required list; (3) update billing system configuration to require prior authorization for those specific drugs when billed to SC Healthy Connections FFS Medicaid members; (4) update clinical staff and providers on the new PA requirement; (5) establish workflow to submit PA requests to Prime Therapeutics Management via https://gatewaypa.com or (800) 424-8219 (8am-5pm M-F) before dispensing or administering the drugs.
02Consequences: Claims for physician-administered drugs on the PA list submitted without prior authorization will be denied by SCDHHS.
Original notice
Updated Prior Authorization Expansion on Physician-administered Drugs
scdhhs.gov · Always check the source before changing claims.
Related changes
See all SC Medicaid - SCDHHS changes →Updated Prior Authorization Expansion on Physician-administered DrugsMediumEffective Dec 15, 2026 · Prior AuthorizationUpdated Prior Authorization Expansion on Physician-administered DrugsHighEffective Jul 1, 2026 · Prior AuthorizationUpdated Prior Authorization Expansion on Physician-administered DrugsMediumEffective Aug 1, 2025 · Prior AuthorizationUpdated Prior Authorization Expansion on Physician-Administered DrugsMediumEffective Nov 15, 2025 · Prior AuthorizationBrowse every SC Medicaid - SCDHHS change in the policy list