Updated January 24, 2022
A South Carolina Medicaid prior authorization form is used by medical professionals who need to request Medicaid coverage for non-preferred therapies (not included on South Carolina Medicaid’s Preferred Drug List). The person making this request must provide clinical reasons for not prescribing a PDL drug. If you require further information, call the phone number provided below.
Fax – 1 (888) 603-7696
Phone – 1 (866) 247-1181
Preferred Drug List – Acceptable drugs by the State
How to Write
Step 1 – Download the fillable PDF form and open it using Adobe Acrobat or Microsoft Word.
Step 2 – Enter the “Request Date” and provide the following “Beneficiary Information” into the appropriate spaces:
- Patient’s full name
- Patient’s Medicaid ID number
- Patient’s date of birth
- Patient’s gender
Step 3 – In the “Prescriber’s Information” section, you are required to enter all of the information listed below.
- Prescriber’s full name
- Prescriber’s NPI number
- Prescriber’s specialty
- Prescriber’s phone and fax number
- Prescriber’s office staff member completing this form
- Pharmacy name and phone number (if known)
Step 4 – Next, in the “Drug Information” section, use the checkboxes to indicate if this is a request for Orlistat, Quantity Limits, PDE5 Inhibitor, or “Other” (enter category). Below that, you must provide the following information regarding the drug that you are requesting coverage for:
- Drug name
- Dosage
- Strength
- Duration
- Diagnostic procedures and findings
- Medical justification for product use
Step 5 – Print the form.
Step 6 – In the indicated fields, provide the “Prescriber’s [handwritten] Signature” and the “Date.”
Step 7 – Fax your request to the appropriate directory.