South Dakota Medicaid Prior Authorization Form

Updated January 23, 2022

A South Dakota Medicaid prior authorization form is a document that is used by medical practitioners in order to request Medicaid coverage for drugs not included on the State-approved Preferred Drug List (PDL). Using this form, the physician will provide a medical justification for making this request. Once completed, this form should be faxed to the South Dakota Department of Social Services Prior Authorization fax number which can be found immediately below this paragraph.

Fax – 1 (866) 254-0761

Phone – 1 (866) 705-5391

How to Write

Step 1 – Download and open the South Dakota Medicaid Prior Authorization Form.

Step 2 – Enter the recipient’s name, Medicaid ID number, and date of birth into the “Recipient Information” section.

Step 3 – Next enter the physician’s name, DEA number, city, phone number, and fax number.

Step 4 – If you are the prescribing physician, enter the name of the requested drug, the drug dosage, and the diagnosis for this request into the indicated fields.

Step 5 – In the “Qualifications for Coverage” section, you will need to provide the following information into the appropriate spaces:

  • Prior therapies
  • Medical justification
  • Adverse reaction(s) or contraindication(s) (attach FDA Medwatch form or provide description)

Provide your signature and the date once the form has been completed and printed.

Step 6 – In the “Pharmacy Information” section, supply the pharmacy name, South Dakota Medicaid Provider number, phone number, fax number, drug name, and NDC number.

Step 7 – Print the form when you are finished entering all of the required information.

Step 8 – Use a pen to tick the appropriate drug category checkbox at the top of the page. Then, sign and date the form where indicated.

Step 9 – Fax the completed request form to the appropriate directory.