South Carolina Healthy Connections Medicaid uses this universal form for pharmacy prior authorization, and it lists the fax line for fee-for-service Medicaid and for each managed care plan. A prescriber meets it when a member's prescription needs approval. The completed form goes to the member's plan, which reviews the drug history and the clinical rationale against medical necessity.
The prescriber or an authorized representative completes all five sections (provider, member, drug information, drug history for the diagnosis, and rationale) and signs.
Download the current version from the source each time; forms change without notice.
Prior Authorization Request Form: Medications
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Yes. The form is universal across South Carolina Medicaid: it asks for the plan name and fax number and prints the fax line for each managed care plan and for fee-for-service Medicaid. Send it to the plan the member is enrolled in rather than to the state.
Whether the member is currently on the drug and for how long, whether the request continues a previous approval, whether strength, dosage or daily quantity changed, and previous treatments for the diagnosis with strength, directions, dates of therapy and reason for failure or discontinuation.