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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.

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
Bonjesta
Diclegis
Sancuso
Zuplenz

Form
Form
Form
Form
Form
Antihistamines
Non-Sedating Antihistamines

Form
Antipsychotics 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
Arcalyst
Bimzelx
Cimzia
Cosentyx
Enbrel
Entyvio
Humira
- Abrilada
- Amjevita
- Cyltezo
- Hadlima
- Hulio
- Hymiroz
- Idacio
- Yuflyma
- Yusmiry
Ilaris
Ilumya
Kevzara
Kineret
Olumiant
Omvoh
Orencia
Otezla
Rinvoq
Siliq
Simponi
Skyrizi
Stelara
Taltz
Tremfya
Velsipity
Xeljanz/XR

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
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
Rosacea - Topical Agents Form
Rukobia 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