South Carolina Medicaid Prior Authorization Form

Updated January 24, 2022

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.