Members

Prior Approval

Prior Authorization for Molina Medicaid Members

You need approval before getting some medical procedures and some medicines. This is called prior authorization (or prior approval). Your primary care provider (PCP) will ask Molina Healthcare of South Carolina for this approval. To find out if you need approval, call Member Services at (855) 882-3901 (TTY: 711).

If approval is needed, your doctor must fill out a form and send it to Molina Healthcare of South Carolina. Molina reviews the request and makes a decision.

  • If the request is approved, your doctor will be told and you can get services.
  • If the request is not approved, you will get a letter telling you why. If you do not agree, you can appeal.

 

Medicines

Some medicines also need approval before you can get them. Your doctor must fill out a form for these medicines.

  • If approved, your doctor will be notified, and you can get your medicine.
  • If not approved, you will get a letter explaining why. If you disagree, you can appeal by calling Member Services.


Ask your doctor if your medicine needs approval when you get your prescription. Most medicines do not need approval.

If a medicine needs approval, you may get a 72-hour emergency supply while waiting. You can get one temporary supply for each prescription. Some items, like inhalers, diabetic supplies, and creams, are given in their smallest package size.

Generic medicines will be given when available. Some medicines for asthma, high blood pressure, diabetes, and high cholesterol may be available in a 90-day supply.

For more information about medicines, appeals, or pharmacies, call Member Services at (855) 882-3901 (TTY: 711). You can also call to suggest changes to the drug list.

Services requiring Prior Authorization by your doctor
  • Advanced Imaging and Specialty Tests
  • Behavioral Health; Mental Health, Alcohol and Chemical Dependency Services
  • Cardiology
  • Cosmetic, Plastic and Reconstructive Procedures
  • Durable Medical Equipment
  • Elective Inpatient Admissions: Acute hospital, Skilled Nursing Facilities (SNF), Acute Inpatient Rehabilitation, Long Term Acute Care (LTAC) Facilities
  • Experimental/Investigational Procedures
  • Genetic Counseling and Testing 
  • Healthcare Administered Drugs
  • Home Healthcare Services (including home-based PT/OT/ST)
  • Hyperbaric/Wound Therapy
  • Long Term Services  
  • Non-Par Providers
  • Nursing Home/Long Term Care
  • Occupational, Physical & Speech Therapy
  • Oncology Services
  • Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedures
  • Pain Management Procedures
  • Pharmacy
  • Prosthetics/Orthotics
  • Sleep Studies
  • Transplants/Gene Therapy, including Solid Organ and Bone Marrow (Cornea transplant does not require authorization).
  • Transportation Services
 
Prior Authorization Report - South Carolina Medicaid (2025)

Below is a summary of prior approval activity for South Carolina Medicaid.

South Carolina Medicaid Prior Authorization Report 2025

Prior Authorization Statistics (aggregated for all items and services)
Molina Healthcare Inc
Percentage
The percentage of STANDARD prior authorization requests that were approved, aggregated for all items and services. 73%
The percentage of STANDARD prior authorization requests that were denied, aggregated for all items and services. 27%
The percentage of STANDARD prior authorization requests that were approved after an appeal, aggregated for all items and services. 18%
The percentage of EXPEDITED prior authorization requests that were approved after an appeal, aggregated for all items and services. 16%
The percentage of STANDARD prior authorization requests for which the review timeframe was extended, and the request was approved, aggregated for all items and services. 58%
The percentage of EXPEDITED prior authorization requests for which the review timeframe was extended, and the request was approved, aggregated for all items and services. 50%
The percentage of EXPEDITED prior authorization requests that were approved, aggregated for all items and services. 89%
The percentage of EXPEDITED prior authorization requests that were denied, aggregated for all items and services. 11%
Timing
Average time that elapsed between the submission of a request and a determination by the payor, plan or issuer, for STANDARD prior authorizations, aggregated for all items and services. (Measured in days) 8
Median time that elapsed between the submission of a request and a determination by the payor, plan, issuer, for STANDARD prior authorizations, aggregated for all items and services. (Measured in days) 9
Average time that elapsed between the submission of a request and a decision by the payor, plan or issuer, for EXPEDITED prior authorizations, aggregated for all items and services. (Measured in hours) 21
Median time that elapsed between the submission of a request and a decision by the payor, plan, issuer, for EXPEDITED prior authorizations, aggregated for all items and services. (Measured in hours) 20