Changes to Administrative Review Procedures of Select Physician Administered Drugs

Effective March 1, 2020, the South Carolina Department of Health and Human Services (SCDHHS) will implement the changes described below for select physician-administered drugs.

SCDHHS contracts with a designated quality improvement organization, KEPRO, for utilization review and prior authorization services. Providers serving Medicaid fee-for-service beneficiaries must receive prior authorization from KEPRO for the following limited list of physician-administered drugs:

Q1 2020

KEPRO Gateway Drugs

Drug Name

KEPRO Gateway Drugs

Drug Name

90378

Synagis

Q5107

Mvasi (biosimilar)

J0222

Onpattro

Q5106

Retacrit (biosimilar)

J9119

Libtayo

Q5114

Ogivri (biosimilar)

J1303

Ultomiris

Q5112

Ontruzant (biosimilar)

J0517

Fasenra

Q5113

Herzuma (biosimilar)

J2786

Cinqair

Q5116

Trazimera (biosimilar)

J2182

Nucala

Q5111

Udenyca (biosimilar)

J3398

Luxturna

Q5108

Fulphila (biosimilar)

J9173

Imfinzi

Q5110

Nivestym (biosimilar)

J9145

Darzalex

Q5103

Inflectra (biosimilar)

J2357

Xolair

Q5104

Renflexis (biosimilar)

J9395

Faslodex

Q5109

Ixifi (biosimilar)

J9047

Kyprolis

 

J9205

Onivyde

J1322

Vimizim

J2350

Ocrevus

J9023

Bavencio

J9022

Tecentriq

J0584

Crysvita

For treatment requests, the Administrative Medication Review (AMR) Authorization Form must be submitted to KEPRO, via fax at (855) 300-0082 and must include supporting medical documentation in order for providers to receive Medicaid reimbursement. Authorization or denial to utilize the physician-administered drug will then be determined with the final deliberation communicated to the provider by KEPRO. Failure to obtain approval prior to the provision of services may result in a claim denial.

A copy of the AMR Authorization Form is included with this bulletin and may be found at https://scdhhs.kepro.com/content/forms.aspx.

Questions regarding this authorization process can be directed to KEPRO at 855-326-5219. Providers with other questions regarding this bulletin should contact the SCDHHS provider service center at 888-289-0709.

Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.

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