The South Carolina Department of Health and Human Services (SCDHHS) is the State agency that administers programs for Medicaid, Children’s Health Insurance Program (CHIP), and Individuals with Disabilities Education Act (IDEA) Part C Program, known as BabyNet. In South Carolina, as in other states, prescription drug coverage is a key component of Medicaid for many beneficiaries who rely on medications for both acute problems and for managing ongoing chronic or disabling conditions. Without Medicaid, many prescription drugs would be prohibitively expensive to low-income beneficiaries. SCDHHS currently contracts with a Pharmacy Benefits Administrator (PBA) to improve the provision of Pharmacy Benefits for the State’s Medicaid providers in a cost-effective manner. Current PBA services include: • Prior authorization and adjudication of Pharmacy claims for all pharmacy and prescribing providers and Medicaid Members • Maintaining transparency in utilization management and assuring coordination of benefits • Using cost avoidance methodology and reducing fraud and abuse • Executes SCDHHS-approved policies, clinical criteria, and the Preferred Drug List (PDL) • Preparing and delivering training materials and training to selected end users of the PBA • Ensuring that the SCDHHS pharmacy benefit is user friendly for pharmacy and prescribing providers and for Medicaid members
