Prior authorization

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
Antiemetics
Akynzeo
Diclegis
Sancuso
Zuplenz

Form
Form
Form
Form
Antihistamines – Oral
Chewable-Liquid-ODT
Tablet-Capsule

Form
Form
Antipsychotics Form
ARBS Form
Amrix/Fexmid Form
Brisdelle Form
Byvalson Form
Cambia, Zipsor, Zorvolex Form
Chronic Constipation Agents
Amitiza, Linzess, Movantik

Form
CGRP Inhibitors
Aimovig, Ajovy, Emgality
Form
Desoxyn Form
Dificid Form
Dupixent Form
Durlaza Form
Emflaza Form
Epidiolex Form
Evzio 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
Hydrocodone/APAP Form
Idiopathic Pulmonary Fibrosis Form
Immunomodulator
Actemra
Cimzia
Cosentyx
Enbrel
Humira
Ilaris
Ilumya
Kevzara
Kineret
Olumiant
Orencia
Otezla
Rinvoq
Siliq
Simponi
Skyrizi
Stelara
Taltz
Tremfya
Xeljanz/XR

Form
Form
Form
Form
Form
Form
Form
Form
Form
Form
Form
Form
Form
Form
Form
Form
Form
Form
Form
Form
Ketoconazole – Topical Agents Form
Lidoderm Form
Luzu Form
Lyrica Form
Metozolv Form
Morphine Equivalent Dose (MED) Limit Form
Moxatag Form
Multiple Sclerosis Form
Narcotics – Brand Name Form
Nasal Steroids Form
Nascobal Form
Nucala Form
Nuplazid Form
Nuvessa Form
Nuvigil/Provigil Form
Onfi Form
Onychomycosis – Topical Agents Form
Onzetra Form
Ophthalmic Antihistamines Form
Opioid – Long Acting and Short Acting Form
Opioid Naïve Form
Oracea/Seysara/Solodyn Form
Oravig Form
Orkambi Form
Otrexup Form
PCSK9 Inhibitors Form
Proton Pump Inhibitors Form
Qualaquin Form
Rayos Form
Relistor Form
Rosacea - Topical Agents Form
Soma 250 Form
Sunosi Form
Tivorbex Form
Tramadol
Ultram ER, tramadol ER
Conzip, Synapryn, Tramadol SR

Form
Form
Triptans
ODT
Tablet

Form
Form
Uloric Form
Viberzi Form
Vimovo/Duexis Form
Vusion Form
Xenazine Form
Xepi Form
Xifaxan Form
Xolair Form
Xyrem Form
Zolpidem
Ambien CR, Edluar, Intermezzo, Zolpimist

Form