The PEBA, the state agency responsible for the administration and management of the state’s retirement systems and employee insurance programs for the state’s public workforce, awarded the contract for pharmacy benefits management services to CVS Caremark. Beginning January 1, 2026, CVS Caremark will replace Express Scripts as the PBM for the State Health Plan. The initial contract term is two years with three one-year renewal options, for a maximum contract term of five years.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

Effective for dates of service on or after August 1, the Department of Health and Human Services (SCDHHS) will require prior authorization (PA) for the physician-administered drugs in the document linked below 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 fee-for-service (FFS) Medicaid 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 August 1. The list of additional drugs is available online. 
 
Requests for PA and questions should be submitted to Prime Therapeutics Management at https://gatewaypa.com or by calling 1-800-424-8219 between 8:00 am-5:00 pm Monday-Friday.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

The Senate Subcommittee Hearing originally scheduled for May 7 has been rescheduled to May 28 at 10:00 am in the Gressette Building, Room 308. NACDS has submitted a support letter for this pivotal legislation for meaningful PBM reform.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

The General Assembly has adjourned, with plans to reconvene in June to address appropriations bills, gubernatorial vetoes and legislation advancing from conference committees. All bills left on the calendar will carry over to the 2026 legislative session, including NACDS reimbursement reform and scope expansion.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

NACDS submitted comments to the Senate Banking and Insurance Committee ahead of its hearing on SB 342, which includes several NACDS priorities related to reimbursement reform. As this marks the first session of a two-year legislative term, NACDS expects to continue advocating for this and related legislation throughout the summer and fall in preparation for the 2026 session.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

NACDS attended in the SC Senate Labor, Commerce, and Industry Committee’s presentations on PBMs and the Future of Pharmacy. The session featured insights from several stakeholders, including the SC Pharmacy Association; Eunice Medina, Director of the SC Department of Health, and Human Services; the Cicero Institute; and the SC Alliance of Health Plans. 

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

The Department of Health and Human Services (SCDHHS) regularly offers free Healthy Connections Medicaid training to enrolled Healthy Connections Medicaid providers and their billing agents. These recurring trainings are conducted by SCDHHS’ contracted vendors. Information about the upcoming February-April trainings and to register for a workshop or find additional training resources, please visit the Medicaid Provider Education website or call the Provider Service Center (PSC) at (888) 289-0709. The PSC’s hours of operation are 7:30 am-5:00 pm Monday-Thursday and 8:30 am-5:00 pm Friday.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

The Department of Health and Human Services (SCDHHS) will operate on an updated schedule for Healthy Connections Medicaid claims submission and payments to accommodate the December 2024 and January 2025 holidays. Due to observance of the Christmas holiday, December 19 at 5:00 pm is the deadline to submit claims for payment date December 27. Electronic remittance advice will be available December 24. Payments will be dated December 27, as usual. Due to observance of the New Year’s holiday, December 27 at 5:00 pm is the deadline to submit claims for payment date January 3. Electronic remittance advice will be available December 31. Payments will be dated January 3rd, as usual. The schedule will return to the normal payment cycle on January 3, 2025.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

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.