Effective for dates of service on or after January 1, 2025, the Department of Health and Human Services (SCDHHS) will require prior authorization (PA) for the physician-administered drugs to ensure use is consistent with the medication’s indication(s) and appropriate clinical guidelines. This change only applies to medications administered to Healthy Connections Medicaid members enrolled in the Medicaid fee-for-service (FFS) program.
The list of physician-administered drugs for which a PA is required when administered to a FFS Medicaid member is available in the Procedure Codes section of the Physicians Services Provider Manual on the SCDHHS website. The list in the manual will be updated with the additional physician-administered drugs requiring a PA beginning January 1, 2025. The list of additional drugs is available online.
Requests for PA and questions about this bulletin should be submitted to Prime Therapeutics at https://gatewaypa.com or by calling (800) 424-8219 between 8:00 am-5:00 pm Monday-Friday.
For more information, contact NACDS’ Leigh Knotts at 803-243-7207.