Policy changes from SC Medicaid - SCDHHS and from Medicaid managed care plans in South Carolina, with the Medicaid prior authorization lists and payer contacts we track for the state. Each item links to its public source.
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.
Humana's new Medicaid pharmacy guidance (effective November 5, 2026) states that select medications such as budesonide, ciclopirox, clindamycin, fluocinonide, ketoconazole, linezolid, nystatin, and vancomycin, when dispensed for mixing into foot baths or soaks, are generally not medically necessary and may lack compendia or label support. Claims for these drugs submitted close together with other foot bath medication claims may reject with NCPDP error code 88 / internal code 527 ('Questionable compendia support'), and medications are approved only if label or compendia-supported use is shown on clinical review.
Humana's pharmacy coverage policy for bevacizumab products (Avastin, Mvasi, Zirabev, Alymsys, Vegzelma, Jobevne) is dated effective 10/28/2026 for Medicare, Medicaid Kentucky, Medicaid South Carolina, and Medicaid Virginia. It sets prior authorization criteria by indication, including a step-therapy requirement that members have an intolerance or contraindication to Mvasi or Zirabev before Avastin, Alymsys, Jobevne, or Vegzelma oncology requests, plus indication-specific diagnosis and regimen requirements. Billing teams should verify these criteria against the current policy version before scheduling affected infusions.
This is historical material (published June 2014, revised October 2026) describing Humana's prior authorization policy for Sylvant (siltuximab) for multicentric Castleman's disease. The policy applies to Medicare, Kentucky Medicaid, and South Carolina Medicaid members who meet specific clinical criteria including HIV/HHV-8 negative status and defined laboratory parameters. Initial and renewal approvals are limited to 6 months or as determined through clinical review.
This is historical material (originally effective January 1, 2020, revised October 28, 2026) describing Humana's non-preferred exception procedure for Medicaid members in Florida, Illinois, South Carolina, and Virginia. The policy outlines how prescribers request exceptions to use non-preferred drugs, the required supporting documentation, and Humana's 24-hour decision timeline. The billing team should verify current applicability with Humana before acting on this guidance, as the discovery date (November 3, 2026) does not confirm whether this policy remains in effect.
This is a historical Kadcyla (ado-trastuzumab emtansine) prior authorization policy originally effective January 1, 2020, with a revision dated October 28, 2026. The policy establishes prior authorization requirements for Kadcyla use in metastatic breast cancer and early breast cancer (HER2-positive) for Medicare, Kentucky Medicaid, and South Carolina Medicaid. The billing team must obtain prior authorization before claims are submitted; claims without prior auth will be denied.
This is historical material (discovered November 2026, originally published June 2020, most recently revised October 28, 2026). Humana requires prior authorization for Trodelvy (sacituzumab govitecan-hziy) for triple-negative breast cancer and HR-positive HER2-negative breast cancer across Medicare, Florida Medicaid, Kentucky Medicaid, and South Carolina Medicaid. The practice must verify current applicability with Humana before taking action, as policies are updated regularly online.
This is a historical prior authorization policy document for Vyvgart and Vyvgart Hytrulo (efgartigimod alfa products) used to treat generalized myasthenia gravis and chronic inflammatory demyelinating polyneuropathy. The policy was originally effective March 23, 2022, and last revised August 1, 2026. The document specifies prior authorization criteria, specialist supervision requirements, and step-therapy requirements that differ between Medicare and Medicaid. This policy is now over 4 years old from original effective date; verify current applicability with Humana's online policy portal before submitting claims.
This is a historical prior authorization policy for Tzield (teplizumab) intravenous solution revised on October 28, 2026 (after the analysis date of November 3, 2026). The policy confirms that Tzield requires prior authorization for Medicare, Medicaid–Kentucky, and Medicaid–South Carolina members with confirmed Stage 2 Type 1 Diabetes. No new billing changes are indicated; this document reaffirms existing prior authorization requirements already in effect since April 26, 2023.
This is a historical policy document (effective 2024-01-01, revised 2026-10-28) that establishes prior authorization requirements for Zaltrap (ziv-aflibercept) in metastatic colorectal cancer. The policy applies to Medicare, Medicaid in Florida, Kentucky, and South Carolina. The billing team should verify this is the current version on Humana's website before taking action, as the discovery date (2026-11-03) does not confirm active applicability.
This is a historical Humana Medicaid pharmacy prior authorization policy for pembrolizumab products (Keytruda, Keytruda Qlex) that became effective January 1, 2025 and was last revised October 28, 2026. The policy establishes prior authorization requirements across multiple cancer indications with specific clinical criteria, combination therapy requirements, and exclusions (including disease progression on prior anti-PD-1/PD-L1 therapy). The billing team must obtain prior authorization before claims are submitted for these drugs across Florida, Kentucky, and South Carolina Medicaid plans.
This is a historical Humana Medicaid prior authorization policy for rituximab products (Rituxan, Ruxience, Riabni, Truxima) effective January 1, 2026, revised October 28, 2026, covering Kentucky and South Carolina Medicaid members. The policy requires prior authorization for all listed indications and establishes clinical criteria including mandatory use of generic/biosimilar alternatives (Ruxience or Riabni) first, with branded products (Rituxan or Truxima) approved only if the member has intolerance or contraindication to the alternatives. The policy was discovered on November 3, 2026, but both the effective date (January 1, 2026) and revision date (October 28, 2026) are in the past relative to the analysis date; the practice should verify current applicability with Humana's online policy portal before implementing.
Humana South Carolina Medicaid established a new prior authorization policy for Zilbrysq (zilucoplan) effective September 23, 2026, for treatment of generalized myasthenia gravis in anti-AChR antibody–positive patients. The policy requires confirmation of diagnosis, antibody status, specialist oversight, and failure or inability to use pyridostigmine plus at least one immunosuppressive therapy before approval. The practice must obtain prior authorization before dispensing this medication or claims will be denied.
Humana has published a new prior authorization policy for Revtorpyk® (gedatolisib), a breast cancer medication effective October 28, 2026, that applies to Medicare, Kentucky Medicaid, South Carolina Medicaid, and Virginia Medicaid. The practice must obtain prior authorization before dispensing this drug and verify that patients meet five specific clinical criteria, including HR-positive/HER2-negative disease without PIK3CA mutation and prior endocrine therapy failure.
Humana South Carolina Medicaid has established a new prior authorization policy for Prolia (denosumab) and eight biosimilars (Jubbonti, Stoboclo, Conexxence, Bildyos, Ospomyv, Enoby, Bosaya, Osvyrti) effective October 28, 2026. The policy covers five indications with specific clinical criteria, including glucocorticoid-induced osteoporosis, osteoporosis, nonmetastatic prostate cancer, hormone-receptor-positive breast cancer, and postmenopausal osteopenia. All claims for these drugs require prior authorization, and the policy includes important clinical guidance regarding hypocalcemia risk, calcium and vitamin D supplementation, and contraindications.
Humana has established a new prior authorization policy for Otarmeni™ (lunsotogene parvec-cwha), a gene therapy for OTOF gene mutation–associated hearing loss, effective October 28, 2026. The practice must obtain prior authorization before administering this treatment to affected members in Florida, Kentucky, South Carolina, and Virginia Medicaid and Medicare plans, and must submit documentation confirming the member meets six clinical criteria including severe-to-profound hearing loss, confirmed OTOF variants, preserved outer hair cell function, no prior cochlear implant, and specialist involvement.
South Carolina Healthy Connections Medicaid has adjusted claims submission deadlines and payment processing dates for November 2026 due to Veterans Day and Thanksgiving holidays. The practice must submit claims by Friday, November 6 at 5 p.m. for the November 13 payment date, and by Friday, November 20 at 5 p.m. for the November 27 payment date. The Provider Service Center will be closed on November 11 and November 26–27.
This Q2 2026 Humana newsletter (published April 1, 2026, discovered November 1, 2026) contains multiple effective dates spanning past, ongoing, and future actions. Key changes include: (1) New prior authorization lists effective July 1, 2026, for Medicare Advantage, Dual Eligible SNPs, and Medicaid plans; (2) Medicaid provider-administered medication PAL changes for seven states; (3) PPO members inactive since May 1, 2024, were automatically unpaneled as of March 1, 2026; (4) New claims-based attribution rules for MA products effective April 1, 2026; and (5) Published claims payment policies including a new Paper Claim Administrative Fee. The newsletter emphasizes timely prior authorization submission before services are fully furnished to avoid claim denial and retroactive authorization processing.
This Q3 2026 Humana newsletter (published July 1, 2026, discovered November 1, 2026) is historical material containing mixed-date guidance. Key items: (1) Clinical documentation for Medicare prior authorizations must be submitted at time of request to meet CMS's 7-day decision requirement—already effective January 1, 2026. (2) Enhanced real-time PA workflow for diagnostic imaging in GA, NC, SC, VA now available. (3) Medicaid medication list updates for five states. (4) New and revised claims payment policies published. (5) Informational resources on safe prescribing, obesity management, and care gap closure. Most actionable items are already in effect or operational.
South Carolina Department of Health and Human Services is increasing reimbursement rates for state plan services and home and community-based services (HCBS) through 1915(c) waiver programs. Rate increases range from $1–$15.23 per unit across personal care, nursing, and residential habilitation services for Healthy Connections Medicaid members. All billing systems and fee schedules will be updated by the effective date.
BlueCross BlueShield of South Carolina is transitioning from MCG Care Guidelines to InterQual Criteria for medical necessity determinations effective January 1, 2027. This change applies to commercial, Medicare Advantage, and Healthy Blue (Medicaid) members across all service categories including inpatient/outpatient procedures, behavioral health, DME, and medical benefit drugs. Prior authorization requirements and submission methods remain unchanged; only the underlying criteria used for medical necessity reviews will shift.
South Carolina DHHS is updating reimbursement and billing guidelines for dental services rendered in ambulatory surgical centers (ASCs), effective December 1, 2026. ASC providers must use procedure code G0330 for operating room–related facility services during dental rehabilitation under anesthesia, with a limit of one billing per patient per date of service at a rate of $1,359. ASCs must submit claims with a copy of the approved authorization issued to the dental provider by SCDHHS' dental administrative services organization, or claims will be rejected.
Humana has established a new prior authorization policy for Genglycos™ (pariglasgene brecaparvovec-opnr), a gene therapy for glycogen storage disease type Ia (GSDIa), effective October 28, 2026. The policy applies to Medicare and four state Medicaid programs (Florida, Kentucky, South Carolina, Virginia) and requires prior authorization with seven clinical criteria before approval, including patient age ≥8 years, confirmed G6PC gene pathogenic variants, absence of pre-existing AAV8 antibodies, and no prior Genglycos administration. Coverage is limited to a single lifetime dose.
South Carolina DHHS is offering free Medicaid provider training across multiple topics (Medicaid Basics, Web Tools, Claim-level Adjustments, ORP Enrollment, and Managed Care Enrollment) scheduled from November 2026 through January 2027. This is an educational opportunity announcement; no billing workflow or policy changes are mandated.
This is historical material: a Folotyn (pralatrexate) pharmacy prior authorization policy originally effective October 29, 2009, with a recent revision date of October 28, 2026 (the analysis date). The policy covers relapsed or refractory peripheral T-cell lymphoma (PTCL) for Medicare and Medicaid (Florida and South Carolina) members. Billing teams should verify current applicability with Humana's online policy portal, as printed copies become uncontrolled and may not reflect the most current version.
This is a historical policy document (original effective date July 24, 2014) that was revised on October 28, 2026. The policy establishes prior authorization requirements for Beleodaq (belinostat) in relapsed or refractory peripheral T-cell lymphoma (PTCL) across Medicare and three state Medicaid programs. The billing team should verify current applicability with Humana rather than treating this as a newly discovered actionable change, since the discovery date (October 28, 2026) matches the revision date but the policy's initial effective date is over 12 years old.
This is historical material: a Humana Clinical Trials Pharmacy Policy originally effective 2016-10-19, newly discovered 2026-10-28. The policy governs coverage of routine care and services costs for members enrolled in federally funded or approved clinical trials for cancer or other life-threatening illnesses, with specific eligibility criteria, exclusions, and requirements for trial approval. The revision date of 2026-10-28 reflects recent policy updates; verify current applicability with Humana's online policy portal before applying.
This is a historical policy document (originally effective 2019-01-01, revised 2026-10-28) that establishes prior authorization requirements for atypical and typical antipsychotic medications when prescribed to members with dementia without appropriate clinical indication. The policy applies to Medicare and multiple state Medicaid programs (FL, IL, SC, IN, OK, VA) and outlines clinical approval criteria based on age, compendia-supported diagnoses, and behavioral severity. The billing team should verify current applicability through Humana's online policy portal rather than relying on this printed version.
This is a historical discovery (published 2021-12-15, found 2026-10-28) of a Humana Medicaid—South Carolina prior authorization policy for Aduhelm (aducanumab-avwa) for Alzheimer's disease treatment. The policy establishes detailed enrollment criteria, renewal requirements, and ARIA monitoring protocols. The most recent revision occurred 2026-10-28. No active changes are described; verify current applicability with Humana directly.
This is a historical policy document (originally effective 2024-07-24, revised 2026-10-28) establishing Humana's prior authorization requirements for Beqvez (fidanacogene elaparvovec-dzkt), a gene therapy for moderate-to-severe hemophilia B. The policy requires prior authorization with specific clinical criteria including age ≥18, factor IX activity ≤2 IU/dL, absence of AAVRh74var neutralizing antibodies, and comprehensive liver/HIV/hepatitis screening. Critical note: Pfizer announced in February 2025 that it will discontinue Beqvez development and commercialization.
Humana has established a new prior authorization policy effective 2026-10-28 for Fayuvi™ (rebisufligene etisparvovec-hopf), a gene therapy for mucopolysaccharidosis type IIIA in pediatric patients. Coverage requires prior authorization and approval for a single lifetime dose across Medicare, Medicaid (Florida, Kentucky, South Carolina, Virginia). The policy mandates five clinical criteria including preserved neurodevelopmental function, confirmed SGSH enzyme deficiency, and low anti-AAV9 antibody titers.
Humana has established a new prior authorization (PA) policy for Decnupaz (pivekimab sunirine-pvzy), a CD123-directed antibody drug conjugate used to treat blastic plasmacytoid dendritic cell neoplasm (BPDCN) in adult patients. The policy requires PA and restricts coverage to monotherapy use only, effective immediately for Medicare, Medicaid Kentucky, and Medicaid South Carolina plans.
Humana has implemented a new Prior Authorization pharmacy coverage policy for bevacizumab products (Avastin, Mvasi, Zirabev, Vegzelma, Alymsys, Jobevne) effective immediately. The policy establishes specific clinical criteria and step-therapy requirements for six oncology indications and three ophthalmology indications across Medicare and three state Medicaid programs (Kentucky, South Carolina, Virginia). Billing staff must verify member eligibility against detailed criteria before processing claims for these drugs.
Humana South Carolina Medicaid establishes new coverage criteria for balloon dilation of the Eustachian tube (BDET) in adults aged 18+ with chronic obstructive ETD refractory to conservative management, requiring prior documentation of hearing evaluation, nasal endoscopy, and otoscopic examination. Posterior nasal nerve ablation procedures remain non-covered due to insufficient evidence.
Humana Medicaid in South Carolina revised its cardiac devices policy effective 10/28/2026, updating coding information from the previous version issued 07/01/2025. The policy covers mobile cardiac outpatient telemetry (MCOT) for specific cardiac indications using CPT codes 93228 and 93229. Billing teams should verify current applicability of coverage criteria and ensure claims are submitted with the correct codes and medical necessity documentation.
Humana revised its South Carolina Medicaid breast procedures policy, effective 2026-10-28. The policy clarifies coverage criteria for breast lesion excision, breast reconstruction, implant removal/replacement, and implant-associated malignancy procedures. Billing teams must verify that prior authorization submissions and claim documentation align with the updated clinical criteria and affected CPT codes.
This is a historical Humana prior authorization policy for corticotropin products (Acthar Gel, Cortrophin Gel) that became effective January 1, 2025 and was last revised March 25, 2026. The policy establishes prior authorization requirements for four indications: West Syndrome in infants under 2 years, acute MS exacerbations, acute exacerbations of rheumatic/collagen/ophthalmic diseases and nephrotic syndrome, and symptomatic sarcoidosis. Billing teams should verify current applicability with Humana, as the source advises checking online for the most up-to-date version before using this policy.
This is a historical policy document (source published 2026-01-01, newly discovered 2026-10-24) establishing Humana's prior authorization requirements for Ocrevus and Ocrevus Zunovo in the treatment of multiple sclerosis across Medicare and three state Medicaid programs. The policy, effective January 1, 2026 with a revision dated June 24, 2026, has already been in effect for over nine months. The billing team should verify current applicability by consulting Humana's online policy portal, as this document may have been superseded.
This is a historical policy document (published January 1, 2026, discovered October 24, 2026) establishing Humana's prior authorization requirements for Briumvi (ublituximab) across Medicare Part B, Medicare Part D, and three state Medicaid programs (Florida, Kentucky, South Carolina). The policy requires step-therapy documentation of prior MS medication trials for Medicare beneficiaries, with exemptions for Medicare Part B continuation therapy and all Medicaid requests. Verify current applicability with Humana before implementing billing changes, as this revision (dated February 25, 2026) may have been superseded.
This is historical guidance (originally effective 2020-01-01, most recently revised 2026-10-21) defining how Humana interprets 'Previous Treatment,' 'Trial,' and 'Prior Therapy' requirements in pharmacy coverage policies across Medicare and multiple state Medicaid programs. The policy clarifies that a single pharmacy claim (typically 28–30 days, or less for certain therapeutic classes) may satisfy prerequisite therapy documentation, unless a shorter timeframe is specified in drug-specific clinical policies. Members in their first 90 days of coverage are exempt from prerequisite therapy review. Billing teams should verify current applicability before applying this guidance to coverage determinations.
This is a historical Medicaid policy document (Humana South Carolina) originally effective July 1, 2021, with a revision dated February 1, 2025, and reviewed October 6, 2026. The policy establishes morphine milligram equivalent (MME) thresholds and prior authorization requirements for opioid medications to reduce overdose and misuse risk. It defines quantity limits, approval criteria, and clinical exceptions for opioid-naive patients, opioid-tolerant patients, and patients exceeding MME thresholds. The policy was newly discovered by PolicyChanges on October 23, 2026, but is not a current change—verify current applicability with Humana directly, as the document advises checking online for the most up-to-date version.
This is a historical policy document (published July 1, 2024, revised January 28, 2026) newly discovered on October 22, 2026. It establishes prior authorization requirements for Zolgensma (onasemnogene abeparvovec-xioi) for pediatric patients under 2 years old with spinal muscular atrophy. The policy has been in effect for nearly 3 years and specifies nine clinical criteria for coverage approval, including genetic confirmation, age limits, SMN2 gene copy limits, and anti-AAV9 antibody titers. Billing teams should verify current applicability with Humana rather than treating this as a new mandate.
This is a historical pharmacy policy document from August 28, 2010, newly discovered on October 21, 2026. The policy establishes Humana's Drug Utilization Management (DUM) and clinical edits framework, including step therapy, quantity limits, prior authorization, accumulation edits, and duplication edits across Medicare and multiple state Medicaid programs. The document was revised on October 21, 2026, but no specific content changes from the original effective date are detailed in this version.
This is a historical policy document from January 1, 2017 that was recently discovered (October 21, 2026). It establishes Humana's framework for pharmacy quantity limitations across Medicare and multiple state Medicaid programs. The policy permits quantity limits based on FDA-approved dosing, medical literature, and treatment guidelines, with exceptions available for dosage titration, compendia-supported dosages, failed trials, or individual member characteristics. The most recent revision is October 21, 2026, but no new effective date or changes are stated in this revision—verify current applicability with Humana's online policy portal.
This is historical material from a Humana Medicaid pharmacy policy originally effective June 3, 2020, revised October 21, 2026. The policy establishes that non-FDA approved medications are excluded from Humana formularies unless reviewed and approved by the Pharmacy and Therapeutics (P&T) Committee. Coverage for approved non-FDA medications is limited to the plan year duration. No new actionable changes are indicated; verify current applicability with Humana before applying this guidance.
This is a historical Crysvita (burosumab) prior authorization policy for X-Linked Hypophosphatemia (XLH) and Tumor-Induced Osteomalacia (TIO) that was originally effective January 1, 2020 and most recently revised February 25, 2026. The policy applies to Medicare and Medicaid (Kentucky and South Carolina) and outlines specific clinical criteria, diagnostic requirements, contraindications, and age-based laboratory thresholds for coverage. The billing team should verify current applicability with Humana before applying this policy, as it was newly discovered on October 17, 2026, despite its 2020 original effective date.
This is a historical Humana pharmacy coverage policy for Enspryng (satralizumab-mwge) for Neuromyelitis Optica Spectrum Disorder (NMOSD) treatment, originally effective January 20, 2021, with a revision dated May 27, 2026. The policy establishes prior authorization requirements for Medicare and Medicaid (South Carolina) members, mandating anti-aquaporin-4 (AQP4) antibody positivity and at least one core NMOSD clinical characteristic. This source was newly discovered on October 17, 2026, but the policy itself predates the discovery date; verify current applicability with Humana before implementing billing changes.
This is historical material: a Humana prior authorization policy for Amondys 45 (casimersen) for Duchenne Muscular Dystrophy, originally effective June 16, 2021, with a revision dated December 17, 2025. The policy establishes prior authorization requirements for this intravenous antisense oligonucleotide therapy, including six initial approval criteria and one renewal criterion based on functional improvement or maintenance. The billing team should verify current applicability through Humana's online policy portal rather than relying on this newly discovered source.
This is a historical Humana prior authorization policy for Viltepso (viltolarsen), a Duchenne Muscular Dystrophy treatment, originally effective January 1, 2022 and most recently revised December 17, 2025. The policy was newly discovered on October 17, 2026, but represents established coverage criteria for Medicare and Medicaid (Kentucky and South Carolina) members. The billing team should verify current applicability with Humana before applying these criteria, as the policy document itself instructs users to check online for the most up-to-date version.
This is a historical policy document (originally effective 2022-01-01, most recently revised 2025-12-17) for Exondys 51 (eteplirsen) coverage under Humana Medicare, Medicaid-Kentucky, and Medicaid-South Carolina plans. The policy requires prior authorization for this Duchenne Muscular Dystrophy treatment and specifies six initial criteria and one renewal criterion for coverage eligibility. The billing team should verify current applicability with Humana before submitting claims, as this document was newly discovered on the analysis date but represents established policy.
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