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Updated Prior Authorization Expansion on Physician-administered Drugs
Act
by Dec 15, 2026
Effective date
Dec 15, 2026
Identified
Nov 7, 2026
Summary
South Carolina Medicaid will require prior authorization for a list of physician-administered drugs when given to fee-for-service Healthy Connections Medicaid members. The drug list is published in the procedure codes section of the Physicians Services Provider Manual and is updated with the added drugs beginning December 15, 2026.
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What to do
by Dec 15, 2026 · 3 steps
01Billing team should review the additional physician-administered drugs list linked from the SCDHHS notice and cross-check it against the drugs your practice administers to Healthy Connections Medicaid fee-for-service members.
02For each matching drug, obtain prior authorization through Prime Therapeutics Management (gatewaypa.com or (800) 424-8219, Monday-Friday 8 a.m.-5 p.m.) before the date of service, and have front desk staff and providers schedule with that requirement in mind.
03Update charge entry and the prior auth tracker so claims for these drugs carry the approved authorization number, and claims without prior authorization will be denied.
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 DrugsHighEffective Oct 1, 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