South Carolina Pharmacy Services

Physician/Prescriber • Documents

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Title
Title
Medication Assisted Treatment Coverage Guidelines

Title
Title
Prior Authorization Request Form: Medications
Antipsychotic - Children ≤ 6 Years of Age PA Request Form
Growth Hormone PA Request Form - Adult Treatment
Growth Hormone PA Request Form - Pediatric Treatment
Health Insurance Referral Form
Hepatitis C PA Request Form
Universal Synagis Authorization Form

Title
Title
Adempas®
Amylin Analogs
Antimigraine Medications
Banzel®
Casgevy®
Clobazam
Continuous Glucose Monitoring (CGM) and Insulin Pumps
DPP4 Inhibitors
Dupixent® and Adbry® for Atopic Dermatitis
Fuzeon®
Fycompa®
Gabitril®
GLP-1 Inhibitors
Growth Hormone with Increlex®
Hepatitis C Agents
Inhaled Cystic Fibrosis Agents
Inpefa®
Lyfgenia™
Miscellaneous
Pulmonary Arterial Hypertension
Renin Inhibitors
Sabril®
SGLT2 Inhibitors
Testosterone
Vigpoder™
Vimpat®
Wegovy for Cardiovascular Events
Weight Management GLP1 Receptor Agonists
Zurzuvae™