South Carolina Pharmacy Services

Physician/Prescriber • Documents

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Title
Medication Assisted Treatment Coverage Guidelines

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
Hepatitis C PA Request Form
Medwatch Form

Title
Adempas®
Amylin Analogs
Antimigraine Medications
Banzel® Tablets and Rufinamide Suspension
Casgevy® for Sickle Cell
Casgevy® for Transfusion Dependent Thalassemia
Continuous Glucose Monitoring (CGM) and Insulin Pumps
DPP4 Inhibitors
Dupixent® and Adbry® for Atopic Dermatitis
Fuzeon®
Endari®
Fycompa®
GLP-1 Receptor Agonists and GLP-1/GIP Receptor Agonists
Growth Hormone with Increlex®
Hepatitis C Agents
Inhaled Cystic Fibrosis Agents
Injectable Immunomodulators
Inpefa®
Kesimpta®
Lyfgenia™
Miscellaneous
Pulmonary Arterial Hypertension
Renin Inhibitors
Sabril®
SGLT2 Inhibitors
Testosterone
Tiagabine
Vigpoder™
Wegovy for Cardiovascular Events
Weight Management GLP1 Receptor Agonists
Xifaxan®
Zurzuvae™