<html xmlns="http://www.w3.org/1999/xhtml"><head><meta charset="UTF-8" /><title></title><meta name="Generator" content="PowerTools for Open XML" /><style>span { white-space: pre-wrap; } p.s6154ee7b-66c2-40d8-809a-a09104299536P0 { margin-top: 0; margin-bottom: 0; margin-left: 0; margin-right: 0; text-indent: 0.00in; text-align: justify; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; line-height: 108%; } span.s6154ee7b-66c2-40d8-809a-a09104299536C0 { color: black; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s6154ee7b-66c2-40d8-809a-a09104299536C0-000000 { color: #0000FF; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s6154ee7b-66c2-40d8-809a-a09104299536C0-000001 { color: black; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s6154ee7b-66c2-40d8-809a-a09104299536C0-000002 { color: #0000FF; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s6154ee7b-66c2-40d8-809a-a09104299536000003 { color: black; background: white; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } </style></head><body><div><p dir="ltr" class="s6154ee7b-66c2-40d8-809a-a09104299536P0"><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536C0">    </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:14:05"><span class="s6154ee7b-66c2-40d8-809a-a09104299536C0-000000">67:16:14:05</span></a><span class="s6154ee7b-66c2-40d8-809a-a09104299536C0-000001">.  Items and services not covered.</span><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536C0"> In addition to the items and services not specifically listed in § </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:14:04"><span class="s6154ee7b-66c2-40d8-809a-a09104299536C0-000002">67:16:14:04</span></a><span class="s6154ee7b-66c2-40d8-809a-a09104299536C0">, the following items and services are not covered under this chapter:</span></p><p dir="ltr" class="s6154ee7b-66c2-40d8-809a-a09104299536P0"><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536000003"> </span></p><p dir="ltr" class="s6154ee7b-66c2-40d8-809a-a09104299536P0"><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536C0">    (1)  Nonlegend prescription drugs and over-the-counter items and medical supplies except for those items covered under § </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:14:04"><span class="s6154ee7b-66c2-40d8-809a-a09104299536C0-000002">67:16:14:04</span></a><span class="s6154ee7b-66c2-40d8-809a-a09104299536C0">;</span></p><p dir="ltr" class="s6154ee7b-66c2-40d8-809a-a09104299536P0"><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536C0">    (2)  Medical supplies or delivery charges;</span></p><p dir="ltr" class="s6154ee7b-66c2-40d8-809a-a09104299536P0"><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536C0">    (3)  Legend oral vitamins except for legend vitamins prescribed for the prenatal care of pregnant women covered under § </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:14:04"><span class="s6154ee7b-66c2-40d8-809a-a09104299536C0-000002">67:16:14:04</span></a><span class="s6154ee7b-66c2-40d8-809a-a09104299536C0">;</span></p><p dir="ltr" class="s6154ee7b-66c2-40d8-809a-a09104299536P0"><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536C0">    (4)  Nicotine patches and other nicotine replacement products;</span></p><p dir="ltr" class="s6154ee7b-66c2-40d8-809a-a09104299536P0"><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536C0">    (5)  Agents to promote fertility or treat impotence;</span></p><p dir="ltr" class="s6154ee7b-66c2-40d8-809a-a09104299536P0"><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536C0">    (6)  Agents used for cosmetic purposes;</span></p><p dir="ltr" class="s6154ee7b-66c2-40d8-809a-a09104299536P0"><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536C0">    (7)  Hair growth products;</span></p><p dir="ltr" class="s6154ee7b-66c2-40d8-809a-a09104299536P0"><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536C0">    (8)  Items or drugs manufactured by a firm that has not signed a rebate agreement with the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services;</span></p><p dir="ltr" class="s6154ee7b-66c2-40d8-809a-a09104299536P0"><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536C0">    (9)  Items </span><span class="s6154ee7b-66c2-40d8-809a-a09104299536C0">that</span><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536C0"> exceed a 34-day supply, except for </span><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536C0">90-day fills on select generic maintenance medications, </span><span class="s6154ee7b-66c2-40d8-809a-a09104299536C0">family planning items</span><span class="s6154ee7b-66c2-40d8-809a-a09104299536C0">,</span><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536C0"> and prenatal vitamins;</span></p><p dir="ltr" class="s6154ee7b-66c2-40d8-809a-a09104299536P0"><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536C0">    (10)  Services, procedures, or drugs considered experimental</span><span class="s6154ee7b-66c2-40d8-809a-a09104299536C0">, not including services, procedures, or drugs approved by the Food and Drug Administration under an emergency use authorization that are being utilized in accordance with the emergency use authorization</span><span class="s6154ee7b-66c2-40d8-809a-a09104299536C0">;</span></p><p dir="ltr" class="s6154ee7b-66c2-40d8-809a-a09104299536P0"><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536C0">    (11)  Drugs and biologicals </span><span class="s6154ee7b-66c2-40d8-809a-a09104299536C0">that</span><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536C0"> the federal government has determined to be less than effective according to Pub. L. No. 97-35, § 2103 (August 13, 1981), 95 Stat. 787; and</span></p><p dir="ltr" class="s6154ee7b-66c2-40d8-809a-a09104299536P0"><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536C0">    (12)  Drugs that did not receive prior authorization from the department under this chapter.</span></p><p dir="ltr" class="s6154ee7b-66c2-40d8-809a-a09104299536P0"><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536000003"> </span></p><p dir="ltr" class="s6154ee7b-66c2-40d8-809a-a09104299536P0"><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536C0">    </span><span class="s6154ee7b-66c2-40d8-809a-a09104299536C0-000001">Source:</span><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536C0"> SL 1975, ch 16, § 1; 1 SDR 77, effective May 29, 1975; 4 SDR 10, effective August 28, 1977; 4 SDR 35, effective December 22, 1977; 7 SDR 23, effective September 18, 1980; 7 SDR 66, 7 SDR 89, effective July 1, 1981; 13 SDR 8, effective August 3, 1986; 14 SDR 46, effective September 28, 1987; 15 SDR 2, effective July 17, 1988; 16 SDR 234, effective July 1, 1990; 17 SDR 200, effective July 1, 1991; 22 SDR 32, effective September 11, 1995; 22 SDR 93, effective January 7, 1996; 28 SDR 166, effective June 12, 2002; 31 SDR 214, effective July 6, 2005; 32 SDR 129, effective February 1, 2006</span><span class="s6154ee7b-66c2-40d8-809a-a09104299536C0">; 47 SDR129, effective June 3, 2021; 48 SDR 39, effective October 3, 2021</span><span class="s6154ee7b-66c2-40d8-809a-a09104299536C0">.</span></p><p dir="ltr" class="s6154ee7b-66c2-40d8-809a-a09104299536P0"><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536C0">    </span><span class="s6154ee7b-66c2-40d8-809a-a09104299536C0-000001">General Authority:</span><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536C0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=28-6-1"><span class="s6154ee7b-66c2-40d8-809a-a09104299536C0-000002">28-6-1</span></a><span class="s6154ee7b-66c2-40d8-809a-a09104299536C0">(1)(2)</span><span class="s6154ee7b-66c2-40d8-809a-a09104299536C0">.</span></p><p dir="ltr" class="s6154ee7b-66c2-40d8-809a-a09104299536P0"><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536C0">    </span><span class="s6154ee7b-66c2-40d8-809a-a09104299536C0-000001">Law Implemented:</span><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536C0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=28-6-1"><span class="s6154ee7b-66c2-40d8-809a-a09104299536C0-000002">28-6-1</span></a><span class="s6154ee7b-66c2-40d8-809a-a09104299536C0">.</span></p><p dir="ltr" class="s6154ee7b-66c2-40d8-809a-a09104299536P0"><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536000003"> </span></p><p dir="ltr" class="s6154ee7b-66c2-40d8-809a-a09104299536P0"><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536C0">    </span><span class="s6154ee7b-66c2-40d8-809a-a09104299536C0-000001">Cross-Reference:</span><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536C0"> Reimbursement for prescribed drugs -- Signed rebate agreement required, Pub. L. No. 101-508, § 4401</span><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536C0"> (August 18, 2021)</span><span class="s6154ee7b-66c2-40d8-809a-a09104299536C0">.</span></p><p dir="ltr" class="s6154ee7b-66c2-40d8-809a-a09104299536P0"><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536000003"> </span></p><p dir="ltr" class="s6154ee7b-66c2-40d8-809a-a09104299536P0"><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536C0">    </span><span class="s6154ee7b-66c2-40d8-809a-a09104299536C0-000001">Notes:</span><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536C0"> </span><span class="s6154ee7b-66c2-40d8-809a-a09104299536C0">Information about drugs that</span><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536C0"> have been determined to be less than effective is available at https://data.medicaid.gov/Drug-Pricing-and-Payment/Drug-Products-in-the-Medicaid-Drug-Rebate-Program/v48d-4e3e/data</span><span class="s6154ee7b-66c2-40d8-809a-a09104299536C0">.</span></p><p dir="ltr" class="s6154ee7b-66c2-40d8-809a-a09104299536P0"><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536000003"> </span></p><p dir="ltr" class="s6154ee7b-66c2-40d8-809a-a09104299536P0"><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536C0">    A list of drugs that require prior approval is available at https://prdgov-rxadmin.optum.com/rxadmin/SDM/Prior_authorization.html</span><span class="s6154ee7b-66c2-40d8-809a-a09104299536C0">.</span></p><p dir="ltr" class="s6154ee7b-66c2-40d8-809a-a09104299536P0"><span xml:space="preserve" class="s6154ee7b-66c2-40d8-809a-a09104299536000003"> </span></p></div></body></html>