Prior Authorization
South Dakota Medicaid supports ePA effective 1/1/2023.
South Dakota Medicaid requires Prior Authorization for the following drugs. All criteria algorithims and forms are in .pdf format. You must have Adobe Acrobat Reader to view the forms. If you do not have Adobe Acrobat Reader, we recommend downloading and installing the latest version.
South Dakota Medicaid requires Prior Authorization for the following drugs. All criteria algorithims and forms are in .pdf format. You must have Adobe Acrobat Reader to view the forms. If you do not have Adobe Acrobat Reader, we recommend downloading and installing the latest version.
| Administrative PA
DAW General PA Max Units Override Medications >$5000 MedWatch Form |
Form Form Form Form Form |
| Acne - Topical Agents | Form |
| Allergen Extract - Oral | Form |
| Altabax | Form |
| Antidepressants | Form |
| Auvelity | Form |
| Antiemetics
Akynzeo Bonjesta Diclegis Sancuso Zuplenz |
Form Form Form Form Form |
| Antihistamines
Non-Sedating Antihistamines |
Form |
| Antipsychotics | Form |
| Lybalvi | Form |
| ARBS | Form |
| Amrix, Fexmid | Form |
| Brexafemme | Form |
| Brisdelle | Form |
| Cambia, Zipsor, Zorvolex | Form |
| Chronic Constipation Agents
Amitiza, Linzess, Movantik |
Form |
| CGRP Inhibitors
Aimovig, Ajovy, Emgality |
Form |
| Continuous Glucose Monitor | Form |
| Desoxyn | Form |
| Dificid | Form |
| Dupixent | Form |
| Durlaza | Form |
| Emflaza | Form |
| Epidiolex | Form |
| Eucrisa | Form |
| Evrydsi | Form |
| Fasenra | Form |
| Genitourinary Smooth Muscle Relaxant | Form |
| GLP-1 Agonist | Form |
| Gralise, Horizant | Form |
| Growth Hormone
Adult-Pediatric Serostim Zorbtive |
Form Form Form |
| Head Lice Medication | Form |
| Hemangeol | Form |
| Hepatitis C | Form |
| Hetlioz | Form |
| Idiopathic Pulmonary Fibrosis | Form |
| Immunomodulator
Actemra - Tyenne
ArcalystAdbry Bimzelx Cibinqo Cimzia Cosentyx Ebglyss Enbrel Entyvio Humira - Abrilada
Ilaris - Amjevita - Cyltezo - Hadlima - Hulio - Hymiroz - Idacio - Simlandi - Yuflyma - Yusmiry Ilumya Kevzara Kineret Nemluvio Olumiant Omvoh Orencia Otezla Rinvoq Siliq Simponi Skyrizi Sotyktu Spevigo Stelara Taltz Tremfya Velsipity Xeljanz/XR Zymfentra |
Form Form Form Form Form Form Form Form Form Form Form Form Form Form Form Form Form Form Form Form Form Form Form Form Form Form Form Form Form Form Form Form Form Form Form Form Form Form Form Form Form Form Form |
| Juxtapid | Form |
| Ketoconazole – Topical Agents | Form |
| Luzu | Form |
| Makena | Form |
| Metozolv | Form |
| Moxatag | Form |
| Multiple Sclerosis | Form |
| Nasal Steroids | Form |
| Nascobal | Form |
| Nucala | Form |
| Nuplazid | Form |
| Nuvessa | Form |
| Nuvigil, Provigil | Form |
| Nuzyra | Form |
| Onfi | Form |
| Onychomycosis – Topical Agents | Form |
| Onzetra | Form |
| Ophthalmic Antihistamines | Form |
| Opioids
Brand Name Narcotics Hydrocodone/APAP Morphine Equivalent Dose (MED) Limit Opioid Naive Opioid - Long Acting & Short Acting |
Form Form Form Form Form |
Opzelura | Form |
| Oracea, Seysara, Solodyn | Form |
| Oravig | Form |
| Orexin Receptor Agonist
Belsomra, Dayvigo, Quviviq |
Form |
| Otrexup | Form |
| PCSK9 Inhibitors | Form |
| Proton Pump Inhibitors | Form |
| Qelbree | Form |
| Qualaquin | Form |
| Rayos | Form |
| Relistor | Form |
| Reyvow, Ubrelvy, Nurtec, Qulipta | Form |
| Rezdiffra | Form |
| Rosacea - Topical Agents | Form |
| Rukobia | Form |
| Seglentis | Form |
| Soma 250 | Form |
| Sunosi, Wakix | Form |
| Tezspire | Form |
| Tirosint/levothyroxine capsule | Form |
| Tivorbex | Form |
| Tramadol
Ultram ER, tramadol ER Conzip, Synapryn, Tramadol SR |
Form Form |
| Triptans
ODT-NS-Tablet Onzetra Xsail |
Form Form |
| Tysabri | Form |
| Uloric | Form |
| Viberzi | Form |
| Vimovo, Duexis | Form |
| Vtama | Form |
| Vusion | Form |
| Xenazine | Form |
| Xepi | Form |
| Xifaxan | Form |
| Xolair | Form |
| Xyrem | Form |
| Zolpidem
Ambien CR, Edluar, Intermezzo,
Zolpimist
|
Form |
| Zoryve | Form |
| Zurzuvae | Form |