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Home » South Dakota » PA Criteria

PA Criteria

South Dakota Department of SocialServices now requires Prior Authorization for the following drugs. All criteria algorithims are in .pdf format. In order to view and print these documents correctly, we recommend downloading the latest version of Acrobat Reader™.

PPI Criteria Xolair Criteria
Amrix / Fexmid Criteria
ARB Criteria Moxatag Criteria
Ambien CR Criteria Immunomodulators
Ultram ER Criteria Uloric Criteria
DAW Criteria Calomist and Nascobal Criteria
Head Lice Medication Criteria Nucynta Criteria
Vusion Criteria Oracea and Solodyn Criteria
Provigil/Nuvigil Criteria Sancuso Criteria
Altabax Criteria  

 

 
 
 
 

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