Physician Administered Drugs, Vaccines and Immunizations

Prior Authorization

Listed below are physician administered drugs, vaccines and immunizations that require prior authorization. Each product has a qualifying criteria document and an associated prior authorization request form to use for submission requests. For products that have multiple treatment indications, please use the appropriate form for the patient's condition.

All prior authorization criteria is developed with the understanding that coverage is inclusive of services that are deemed medically necessary as outlined in the South Dakota Administrative Rules (SDAR 67:16:01:06.02). Determination of prior authorization status for all physician administered drugs can be done via the use of our Procedure Code Look-Up Tool.

For concerns regarding prior authorization criteria, please submit a coverage request using the Medicaid Portal.

Submission

Prior Authorization requests should be submitted to South Dakota Medicaid via secure email. Use secure email to send completed documentation to DSSMedicaidPA@state.sd.us.

If secure email is unavailable, mail or fax completed documentation to:

South Dakota Department of Social Services
Division of Medical Services
Attn: Prior Authorization
700 Governors Drive
Pierre SD 57501
Fax 605.773.5246