South Dakota Medicaid GLP-1 Coverage 2026: Pattern #45 — Operational AOM Exclusion By Absence (No Codified Categorical Language; the OptumRx GLP-1 PA Form Pre-Codes ONLY T2D as the Indication Checkbox) Under FFS-Only DSS Division of Medical Services After 2022 Ballot Amendment D Expansion and HJR 5001 Sending Constitutional Amendment I (90% FMAP Trigger) to the November 3, 2026 Ballot

TL;DR — what South Dakota Medicaid covers and does not cover

The exclusion is operational, not codified. The SD Medicaid Pharmacy Services Billing & Policy Manual (December 2025) page 5 verbatim describes the PDL architecture:

“South Dakota Medicaid has a limited preferred drug list (PDL). … If a drug is not listed on the PDL that means it is not subject to the PDL. … All drugs, whether on the PDL or not, may be subject to prior authorization criteria (PA).”

The SD-specific GLP-1 Agonists Prior Authorization Request Form (footer ID GLP1Agonists_SouthDakotaMedicaid_2026May, May 2026 revision) scopes the indication checkbox verbatim:

“Clinical Information (required) / Select the diagnosis below: / ☐ Type 2 diabetes mellitus / ☐ Other diagnosis: ______________________________ ICD-10 Code(s): ____________________________”

What SD Medicaid does NOT cover (functionally excluded by the absence of any obesity-coverage criteria and the T2D-only scoping of the GLP-1 PA form):

• Wegovy (semaglutide) for obesity
• Zepbound (tirzepatide) for obesity
• Saxenda (liraglutide) for obesity
• Imcivree (setmelanotide)
• Qsymia (phentermine/topiramate)
• Contrave (naltrexone/bupropion)
• Orlistat (over-the-counter and prescription)
• Phentermine (Adipex-P, Lomaira, generic)
• Compounded semaglutide and compounded tirzepatide (not FDA-approved finished products; SD Medicaid requires FDA approval plus federal rebate agreement)

What SD Medicaid covers for T2D-indicated use (subject to PA via OptumRx):

• Ozempic (semaglutide) for T2D
• Mounjaro (tirzepatide) for T2D
• Trulicity (dulaglutide) for T2D
• Victoza (liraglutide) for T2D
• Rybelsus (semaglutide tablets) for T2D
• Exenatide (Byetta, generic) for T2D

UNVERIFIED carve-outs (no SD-specific guidance published as of May 15, 2026):

• Wegovy CV (cardiovascular risk reduction in established CVD)
• Zepbound OSA (moderate-to-severe obstructive sleep apnea)
• Wegovy MASH (metabolic dysfunction-associated steatohepatitis)
• Pediatric Wegovy (ages 12+)

The PA form’s “Other diagnosis” line provides a theoretical pathway for non-T2D FDA-indicated uses, but no published criterion confirms SD will approve any. Prescribers seeking carve-out access should call OptumRx directly at 1-855-401-4262 to verify operational availability before submitting.

Architectural distinctive features:

• Operational exclusion by absence — no codified “anti-obesity drugs are not covered” sentence anywhere; the exclusion operates because the PA form is T2D-scoped and no obesity criteria are published. Distinctive in the 50-state series.
• FFS-only architecture — no comprehensive MCOs. KFF May 2025 Managed Care < 0.5%. One of approximately 10 such states. No MCO-internal appeals layer.
• Ballot-initiative Medicaid expansion — Amendment D approved November 8, 2022 (56.21% yes / 43.79% no) effective July 1, 2023. SD is one of approximately 7 states that expanded by direct voter initiative.
• Constitutional Amendment I on the November 3, 2026 ballot — would condition Medicaid expansion on federal FMAP remaining at or above 90%. HJR 5001 referred Amendment I to the ballot via House 59-7 (Jan 21, 2025) and Senate 31-3 (March 3, 2025). Uniquely constitutionalized FMAP-trigger architecture.
• OptumRx pharmacy claims processor since November 13, 2017. Commercial PBM subsidiary of UnitedHealth Group.
• Limited PDL architecture — coverage gating runs primarily through PA criteria, not PDL preferred/non-preferred tiering. Different from most state PDL architectures.
• Tribal health overlap — SD has 9 federally recognized tribes; IHS/tribal facility utilization meaningful share of Medicaid utilization. AOM exclusion still applies despite 100% FMAP at IHS facilities.

Pharmacy benefit architecture:

• Pharmacy claims processor: OptumRx (effective November 13, 2017)
• PA fax (non-urgent): 1-844-403-1029, Mon-Sat 7am-7pm Central
• Urgent/expedited phone: 1-855-401-4262
• General OptumRx FFS Pharmacy PA support: 855-401-4262
• General fax (FFS Pharmacy PA): 800-527-0531
• OptumRx SDM PDL portal: sdm.pharmacy.optum.com/pdl
• OptumRx SDM general site: sdm.pharmacy.optum.com
• Day-supply cap: 34 days maximum
• High-dollar PA: any claim exceeding $5,000 requires PA

1. Federal authority: 42 U.S.C. § 1396r-8(d)(2)(A) exercised by operational silence

The federal Medicaid drug rebate statute at 42 U.S.C. § 1396r-8(d)(2)(A) grants states an optional authority to exclude “agents when used for anorexia, weight loss, or weight gain” from coverage. Most states in the 50-state series exercise this authority by explicit codification:

• Vermont (Pattern #41): PDL effective April 17, 2026 verbatim — “Drugs used for weight loss, drugs used to promote fertility, and drugs used for cosmetic purposes or hair growth are excluded from coverage under the Vermont Medicaid Pharmacy program.”
• Montana (Pattern #46): DPHHS Pharmacy Program verbatim — “Not Covered: Unapproved drugs, experimental medications, fertility drugs, weight-loss medications, cosmetic treatments, erectile dysfunction drugs, and non-formulary OTC drugs.” + Prescription Drug Program Manual verbatim — “The program explicitly does not reimburse for drugs prescribed for weight reduction.”
• Maine (Pattern #39): anchors the exclusion in a freestanding state regulation at 10-144 C.M.R. ch. 101, Ch. II, § 80.06(A).
• Mississippi (Pattern #35): executes a State Plan Amendment carve-back-in via SPA 23-0013.
• Arkansas (Pattern #34): ACT 628 explicit weight-loss exclusion enacted January 1, 2026.

South Dakota is structurally different. There is NO codified verbatim statement that South Dakota Medicaid does not cover weight-loss drugs. The SD Medicaid Pharmacy Services Billing & Policy Manual (December 2025) does not contain explicit categorical AOM exclusion language. The SD Medicaid Pharmacy Provider page does not enumerate “weight-loss medications” in a Not Covered bucket. The exclusion operates by:

1. PDL gating verbatim from manual page 5: “South Dakota Medicaid has a limited preferred drug list (PDL). … All drugs, whether on the PDL or not, may be subject to prior authorization criteria (PA).”
2. PA-form scoping: the OptumRx-administered SD-specific GLP-1 Agonists Prior Authorization Request Form (footer ID GLP1Agonists_SouthDakotaMedicaid_2026May) limits the diagnosis-checkbox field to “☐ Type 2 diabetes mellitus / ☐ Other diagnosis: ___ ICD-10 Code(s): ___”.
3. Federal rebate gatekeeping verbatim from manual page 2: “To be eligible for coverage, all products must be FDA approved and have an existing federal rebate agreement.” Drug coverage for FDA-approved indications is in principle allowable but with PA gatekeeping that is not operationally available for obesity indications.

The federal authority is therefore exercised through operational mechanism rather than statutory codification. The end result is operationally identical to a categorical-exclusion state, but the absence of codified language has practical implications: there is no readable statute or regulation to cite when arguing for legislative reform, and prescribers must inform patients via the PA form scoping rather than via a clear “Not Covered” published list.

2. The SD-specific GLP-1 Agonists PA Request Form: the exclusion mechanism verbatim

The operative mechanism for the SD Medicaid AOM exclusion is the SD-specific GLP-1 Agonists Prior Authorization Request Form administered by OptumRx. Footer ID: GLP1Agonists_SouthDakotaMedicaid_2026May (May 2026 revision). Available at contenthub-aem.optumrx.com.

2.1 The form’s structure verbatim

“GLP-1 Agonists Prior Authorization Request Form / DO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED”

“Member Information (required) … Provider Information (required) … Medication Information (required): / Medication Name: ___ Strength: ___ Dosage Form: ___ / ☐ Check if requesting brand / ☐ Check if request is for continuation of therapy / Directions for Use: ___”

“Clinical Information (required) / Select the diagnosis below: / ☐ Type 2 diabetes mellitus / ☐ Other diagnosis: ______________________________ ICD-10 Code(s): ____________________________”

“Quantity limit requests: / What is the quantity requested per MONTH? _________ / What is the reason for exceeding the plan limitations? / ☐ Titration or loading dose purposes / ☐ Patient is on a dose-alternating schedule (e.g., one tablet in the morning and two tablets at night, one to two tablets at bedtime) / ☐ Requested strength/dose is not commercially available / ☐ Other: ___”

“Are there any other comments, diagnoses, symptoms, medications tried or failed, and/or any other information the physician feels is important to this review? …”

“Please note: This request may be denied unless all required information is received. / For urgent or expedited requests please call 1-855-401-4262. / This form may be used for non-urgent requests and faxed to 1-844-403-1029.”

2.2 What the PA form does and does NOT contain

What the form contains:

• Type 2 diabetes mellitus checkbox as the first and primary diagnosis option
• “Other diagnosis” free-text line with ICD-10 Code(s) field
• Quantity-limit override checkboxes for titration, dose-alternating schedules, commercial availability, and other
• Free-text comments / clinical information field
• Brand override checkbox
• Continuation-of-therapy checkbox

What the form does NOT contain:

• No step-therapy prerequisites pre-printed (no metformin failure attestation)
• No BMI thresholds
• No HbA1c thresholds
• No obesity/E66 ICD-10 pathway as a separate checkbox
• No reference to Wegovy MACE, Zepbound OSA, or Wegovy MASH carve-out criteria
• No reference to pediatric (ages 12+) Wegovy criteria
• No reference to BMI > 30 OR BMI > 27 with comorbidity adult-obesity thresholds

2.3 The “Other diagnosis” field — theoretical pathway, no published criterion

The PA form’s “Other diagnosis” free-text line provides a theoretical pathway for non-T2D FDA-indicated uses. A prescriber could theoretically enter ICD-10 E66.9 (Obesity, unspecified), I25.2 (Old myocardial infarction), G47.33 (Obstructive sleep apnea, adult), or K76.81 (NAFLD), and complete the “Other diagnosis” line with appropriate clinical justification. However:

1. No published criterion confirms SD will approve any such request. The SD Medicaid Pharmacy Services Billing & Policy Manual (December 2025) does not contain any operative carve-out criteria for obesity, CV risk reduction, OSA, MASH, or pediatric weight management.
2. OptumRx adjudicates based on programmatic clinical criteria that are not published in the SD-specific PA form. The clinical criteria OptumRx uses for SD Medicaid GLP-1 review beyond the T2D checkbox are not transparent in public-facing documents.
3. Prescribers seeking carve-out access should call OptumRx directly at 1-855-401-4262 before submitting to verify whether the requested indication has operational coverage criteria. Submitting an “Other diagnosis” obesity-indication PA without prior verbal confirmation risks a denial that consumes the 30-day appeal clock without recoverable strategy.

3. FFS-only architecture: no comprehensive Medicaid MCOs

South Dakota operates a fee-for-service (FFS) Medicaid pharmacy benefit with no comprehensive risk-based managed care organizations. Per the KFF Medicaid-in-SD fact sheet (May 2025) verbatim: “Managed Care < 0.5% … Fee-for-Service.” South Dakota is one of approximately 10 states without comprehensive Medicaid managed care — a structurally distinctive feature in a national landscape where the great majority of Medicaid spending flows through capitated MCO contracts.

3.1 Implications for GLP-1 coverage

The FFS-only architecture has direct implications for GLP-1 coverage policy and member experience:

• One statewide pharmacy benefit administered by DSS Division of Medical Services. OptumRx is the single claims processor. There is no MCO-specific formulary variation. A Sioux Falls beneficiary, a Rapid City beneficiary, a Pine Ridge beneficiary, and a Pierre beneficiary all face the same OptumRx-administered PA pathway and the same T2D-only PA form scoping.
• No MCO-internal appeals layer. In capitated-MCO states (e.g., Kansas Pattern #43 with Sunflower / UHC / Healthy Blue, Delaware Pattern #42 with Highmark Health Options / AmeriHealth Caritas / Delaware First Health, RI Pattern #40 with NHPRI / UHC), PA denials typically route through the MCO’s internal appeal process before reaching the state fair hearing. In South Dakota, denials route directly from OptumRx adjudication to DSS reconsideration to OAH fair hearing — a one-step appeal architecture rather than two-step.
• Policy lever is at DSS. The path to expanding GLP-1 coverage in South Dakota is through DSS Division of Medical Services policy change — publication of new PA criteria for obesity-indicated GLP-1 use — or through state legislation. There is no MCO-contract negotiation pathway.
• KFF cohort exclusion follows architecturally. Because the single statewide pharmacy benefit lacks any obesity-coverage criteria and the sole GLP-1 PA form is T2D-scoped, South Dakota cannot appear in the KFF 13-state coverage cohort without a DSS-level operational change.

3.2 Why FFS-only matters for prescribers

Prescribers writing GLP-1 prescriptions for SD Medicaid beneficiaries operate against a single uniform PA pathway. Practical implications:

• One PA form for all GLP-1s. There is no need to look up which MCO covers the patient and to navigate MCO-specific PA forms. The OptumRx-administered SD-specific GLP-1 Agonists PA Form is the master form across all SD Medicaid beneficiaries.
• One PA fax (1-844-403-1029) and one urgent phone (1-855-401-4262) for all SD Medicaid GLP-1 PA submissions.
• OptumRx adjudication consistency. The same OptumRx clinical reviewers apply the same programmatic criteria across all SD Medicaid GLP-1 requests, providing predictability that varies by state-MCO architecture elsewhere.
• Appeal predictability. The one-step appeals architecture (DSS reconsideration → OAH fair hearing) eliminates the MCO-internal-appeal step that can add 30-60 days to capitated-MCO state appeals timelines.

4. Ballot-initiative Medicaid expansion: Amendment D (2022) and Amendment I (2026)

4.1 Amendment D (November 8, 2022) — voter-approved expansion

South Dakota expanded Medicaid by direct voter initiative. Constitutional Amendment D was approved on November 8, 2022 with 56.21% yes / 43.79% no. The Amendment took effect July 1, 2023 and expanded Medicaid eligibility to adults aged 18-65 with incomes up to 138% of the Federal Poverty Level. South Dakota is one of approximately 7 states that expanded Medicaid by direct voter initiative, after:

• Maine (2017) — voter-approved expansion via Question 2
• Idaho, Nebraska, and Utah (2018)
• Missouri and Oklahoma (2020)
• South Dakota (2022)

Expansion enrollment varies by reporting source and reference date:

• KFF May 2025: approximately 24,000 expansion enrollees
• CMS October 2025 (June 2025 data): 29,843 expansion enrollees
• SD Legislative Research Council November 2025 (Stateline): 28,726 expansion enrollees

The expansion enrollment of approximately 28,000-30,000 represents the working-age, low-income, non-elderly, non-disabled adult population that was not previously eligible for Medicaid. This is the population most likely to seek GLP-1 access for obesity if and when SD Medicaid develops obesity-coverage criteria — making the trajectory of Amendment D and Amendment I directly relevant to the future of GLP-1 coverage in South Dakota.

4.2 HJR 5001 (2025 session) — referring Constitutional Amendment I to the ballot

HJR 5001 was the joint resolution that referred Constitutional Amendment I to the November 3, 2026 general election ballot. The resolution would amend the South Dakota Constitution to condition the continuation of Medicaid expansion on the federal Medical Assistance Percentage (FMAP) for the expansion population remaining at or above 90%. If voters approve Amendment I and FMAP subsequently drops below 90%, the expansion would auto-sunset — Medicaid coverage for the approximately 28,000-30,000 expansion adults would be removed.

Legislative passage of HJR 5001:

• House: passed 59-7 on January 21, 2025
• Senate: passed 31-3 on March 3, 2025
• Senate sponsor: Sen. Casey Crabtree (R)
• Ballot reference: Constitutional Amendment I on the November 3, 2026 general election ballot

The 2025 South Dakota House also considered a direct proposal to repeal Medicaid expansion outright, but that proposal was stopped by the House. The HJR 5001 trigger architecture is the surviving 2025 vehicle for legislative-conditioned expansion sunset.

4.3 Why the FMAP-trigger architecture is uniquely constitutionalized

FMAP-trigger laws conditioning Medicaid expansion on continued federal funding are present in approximately 15 states (varying federal-funding-level triggers in MT, AZ, AR, IL, IN, IA, MI, NH, NM, NC, OH, UT, VA, WA, and others). Most trigger laws are enacted by ordinary state legislation — they can be amended or repealed by simple majority of the state legislature in subsequent sessions.

South Dakota’s Constitutional Amendment I — if approved by voters on November 3, 2026 — would constitutionalize the FMAP-trigger architecture. This means:

• Higher procedural bar to amend or repeal. Amending the SD Constitution requires either a constitutional convention or a ballot-referred amendment approved by voters; ordinary legislative repeal is not available.
• Built-in legal contingency on federal funding. If Congress modifies FMAP for the expansion population below 90% — whether through budget legislation, reconciliation, or other mechanisms — SD expansion auto-sunsets without further state legislative action required.
• Direct linkage to federal policy. The trigger architecture means SD expansion is structurally vulnerable to federal Medicaid policy shifts in a way that non-constitutionalized trigger states are not. Federal H.R. 1 / OBBBA-driven changes effective July 1, 2026 (which Kansas Pattern #43 navigated via SB 363 / HB 2731) become directly relevant to SD’s expansion continuity if Amendment I is approved.

4.4 Implications for GLP-1 coverage trajectory

Amendment I does not directly address GLP-1 or anti-obesity-medication coverage. It conditions WHO is covered (the 28K-30K expansion adults) on FMAP — not WHAT is covered. However, the policy story matters for the GLP-1 coverage trajectory:

• Fiscal pressure. If Amendment I is approved and FMAP drops, the expansion population would be removed entirely — eliminating any practical question of GLP-1 obesity coverage for that population. The expansion adults are the working-age, low-income demographic most likely to seek GLP-1 access for chronic weight management.
• Legislative bandwidth. The Legislature’s 2025 session focused on Medicaid permanence and trigger questions (HJR 5001 and the failed repeal proposal). There was no bandwidth for AOM-mandate legislation analogous to MT SB 417 or ME LD 480. The 2027 session will likely be similarly focused on post-Amendment-I trajectory rather than AOM coverage.
• Policy lever depth. The path to obesity-indicated GLP-1 coverage in SD Medicaid is now layered: DSS Division of Medical Services would need to publish new PA criteria; the Legislature would likely need to authorize or fund the coverage; the FMAP trigger architecture (if Amendment I passes) layers on top.

5. PA pathway: OptumRx contact architecture and adjudication timing

5.1 OptumRx contact information

• PA fax (non-urgent): 1-844-403-1029, Mon-Sat 7am-7pm Central
• Urgent/expedited phone: 1-855-401-4262
• General OptumRx FFS Pharmacy PA support: 855-401-4262
• General fax (FFS Pharmacy PA): 800-527-0531
• OptumRx SDM PDL portal: sdm.pharmacy.optum.com/pdl
• OptumRx SDM general site: sdm.pharmacy.optum.com
• SD Medicaid Pharmacy Provider page: dss.sd.gov/medicaid/providers/programinfo/pharmacy/

5.2 Adjudication timing verbatim

Per the SD Medicaid Pharmacy Services Billing & Policy Manual (December 2025), page 5 verbatim:

“Most PA requests are adjudicated within 72 hours. A ‘clean’ request is often adjudicated in less than 24 hours. A PA will have an end date, typically one year, after which a new PA must be submitted. PAs are not open ended. PAs will not be backdated, a prescription filled prior to a PA being obtained is the responsibility of the patient.”

Operational implications:

• 72-hour standard window for most PA requests. This is consistent with the federal floor and aligns with peer-state Medicaid pharmacy PA windows.
• < 24-hour clean-request window. Where the PA is complete with all required fields, the typical adjudication is faster — comparable to Montana’s “typically decided immediately” standard (Pattern #46) but with a more explicit 24-hour benchmark.
• One-year PA end date. PAs are time-bounded; a new PA must be submitted annually for ongoing therapy. Prescribers should diary-track approval expirations to avoid lapses in continuation-of-therapy coverage.
• No backdating. A prescription filled before PA approval is the patient’s financial responsibility — even if the PA is subsequently approved. This is a hard rule: prescribers should counsel patients to wait for PA approval before filling, except where the 5-day emergency-fill rule applies.

5.3 5-day emergency-fill rule

Verbatim from the SD Medicaid Pharmacy Services Billing & Policy Manual:

“An emergency claim of up to five days fill is allowed in cases where a delay in seeking a PA would negatively impact patient care and a PA cannot be obtained due to circumstances beyond the control of the pharmacy or patient (ex. holiday, prescriber not available).”

The 5-day emergency fill provides bridge coverage for T2D-indicated GLP-1 continuation cases where the prescribing endocrinologist is unavailable (weekends, holidays) and the patient is running out of supply. The pharmacy dispenses up to 5 days of supply at point of sale; the prescriber files the full PA in parallel via OptumRx.

5.4 34-day day-supply cap

SD Medicaid imposes a 34-day maximum day-supply cap on most pharmacy fills, including GLP-1 fills. Practical effect: monthly fills are standard (e.g., one 28-day Wegovy pen-injector); 90-day mail-order fills typical in commercial pharmacy benefit are not available under SD Medicaid for GLP-1s. Prescribers and patients should plan for monthly fill cadence rather than quarterly.

5.5 High-dollar PA layer ($5,000 threshold)

Verbatim from the manual:

“Any claim exceeding $5,000 requires prior authorization.”

Most GLP-1 monthly fills at average wholesale price (AWP) land near or above $5,000. Wegovy AWP runs approximately $1,400-$1,800 per month at typical AWP markups; Zepbound AWP runs similar. A single monthly fill of injectable GLP-1 at most AWP levels with associated dispensing fees and pharmacy markups can plausibly cross the $5,000 threshold — especially after pharmacy benefit reimbursement is calculated. The practical effect: even where a T2D-indicated GLP-1 fill would clear the standard PA, the high-dollar PA layer may apply separately. Pharmacy claim systems generally adjudicate both PA layers automatically, but the high-dollar threshold is an additional check for prescribers and pharmacies to be aware of when assembling supporting documentation.

6. Appeals pathway: 30 days to OAH, 90-day ALJ decision

South Dakota Medicaid uses a single-step fair-hearing appeals architecture administered by the SD Department of Social Services Office of Administrative Hearings (OAH).

6.1 Filing deadline verbatim

Filing deadline from the SD Medicaid Recipient Rights & Responsibilities page:

“Hearing requests must be made within 30 days from the date the written notice was received.”

Reinforced by the SD Medicaid Reconsideration Reviews, Coverage Requests, and Fair Hearings Manual (February 2025) verbatim:

“A request for an appeal must be made to the Office of Administrative Hearings within 30 days of the decision date from South Dakota Medicaid.”

The 30-day window is tighter than peer states like Vermont (60-day DVHA internal appeal + 120-day Human Services Board fair hearing) and Rhode Island (120-day MCO appeal). It is comparable to North Carolina’s and Texas’s 30-day windows. SD Medicaid beneficiaries should act promptly upon receipt of an adverse action notice.

6.2 ALJ decision timeline verbatim

“the ALJ must issue a final decision within 90 days (60 days in food stamp cases).”

The 90-day ALJ decision window aligns with the 42 CFR 431.244(f)(1) federal floor for Medicaid fair hearings. The 60-day food-stamp variant reflects the SNAP-specific federal regulation at 7 CFR 273.15(c)(1).

6.3 Evidence rule verbatim

“Submit your exhibits to the ALJ at least 5 days before the hearing.”

The 5-day pre-hearing evidence submission rule is consistent with administrative-hearing standards. Beneficiaries (or their representatives) should organize all supporting clinical documentation — PA denial notice, clinical chart notes, prior medication history, prescriber justification letter, FDA labeling references, peer-reviewed evidence — with sufficient lead time to submit at least 5 calendar days before the scheduled hearing.

6.4 OAH contact information

• Address: Department of Social Services, Office of Administrative Hearings, 700 Governors Drive, Pierre, SD 57501
• Phone: 605.773.6851
• Fax: 605.773.6873
• Email: admhrngs@state.sd.us
• SD DSS OAH Fair Hearings landing: dss.sd.gov/keyresources/adminhearings/fairhearing.aspx
• SD DSS How to Request a Fair Hearing: dss.sd.gov/keyresources/adminhearings/request.aspx

6.5 Expedited fair hearings — UNVERIFIED

UNVERIFIED: The DSS Fair Hearings page does not document an SD-specific expedited pathway for cases where the standard 90-day cycle would jeopardize patient health. The federal floor under 42 CFR § 431.224 requires expedited fair-hearing processing where life or health is jeopardized — typically with a 72-hour or comparable accelerated cycle. Beneficiaries seeking expedited consideration for a GLP-1 coverage dispute should specifically cite 42 CFR § 431.224 in the hearing request and document the medical urgency.

6.6 Continuation of benefits during appeal — UNVERIFIED

UNVERIFIED: The SD Medicaid Recipient Rights & Responsibilities page does not document whether benefits continue during a pending appeal. Federal Medicaid regulations at 42 CFR § 431.230 and § 431.231 require continuation of benefits pending fair hearing where the beneficiary requests a hearing before the adverse-action effective date. SD-specific implementation of the continuation rule is not transparent in the publicly accessible documents reviewed during verification on May 15, 2026. Beneficiaries should explicitly request continuation of benefits at the time of hearing-request filing.

6.7 Provider reconsideration (separate from member fair hearing)

Providers (pharmacies and prescribers) have a separate reconsideration pathway distinct from the member fair-hearing path. Provider reconsideration is submitted via the Medicaid Portal Communications tab, within 6 months of date of service or 3 months of denial remittance, whichever is later. Provider reconsideration is for billing-and-coding disputes (e.g., claim denial for incorrect modifier, fee schedule disputes, third-party-liability disputes) rather than for clinical PA disputes — clinical PA denials are appealed by the member through OAH.

7. T2D-indicated GLP-1 coverage

Type 2 diabetes-indicated GLP-1 receptor agonists (Ozempic, Mounjaro, Trulicity, Victoza, Rybelsus, Exenatide) are covered under SD Medicaid with prior authorization via OptumRx. The SD-specific GLP-1 Agonists Prior Authorization Request Form explicitly lists “☐ Type 2 diabetes mellitus” as the first diagnosis-checkbox option.

7.1 Notable absences on the PA form

The SD-specific GLP-1 PA form has several distinctive absences relative to peer-state GLP-1 PA forms:

• No step-therapy prerequisites pre-printed. There is no metformin failure attestation checkbox, no sulfonylurea trial requirement, no DPP-4 inhibitor failure requirement. The PA form does not pre-code step-therapy obligations onto the prescriber attestation.
• No BMI thresholds. There is no BMI ≥ 30 or BMI ≥ 27 comorbidity threshold pre-printed on the form. Adult-obesity BMI gates are absent.
• No HbA1c thresholds. There is no HbA1c ≥ 7.0% or HbA1c ≥ 8.0% threshold pre-printed for T2D documentation. Prescribers should still document HbA1c on the free-text clinical information field.
• No prior-medication-history pre-printed checkboxes. Prior medication history must be documented in the free-text comments / clinical information field rather than via structured checkboxes.

7.2 Programmatic OptumRx criteria

Step therapy and quantity limits are adjudicated programmatically by OptumRx after submission. The clinical criteria OptumRx uses for SD Medicaid T2D-indicated GLP-1 review — beyond the T2D checkbox — are not transparent in the publicly accessible SD-specific PA form or in the SD Medicaid Pharmacy Services Billing & Policy Manual. Prescribers should anticipate that OptumRx will apply standard programmatic criteria including metformin step-therapy expectations and HbA1c thresholds, even though these are not pre-printed on the PA form.

7.3 Prescriber documentation checklist

Recommended documentation for T2D-indicated GLP-1 PA submission to OptumRx (based on general Medicaid PA standards; SD-specific programmatic criteria are not transparent):

• T2D diagnosis with ICD-10 code (E11.x for Type 2 diabetes mellitus)
• Baseline HbA1c and most recent HbA1c (preferably within 90 days)
• Prior medication history including metformin trial and outcome (start date, dose, duration, response, adverse events or intolerance)
• Trial history with second-line classes (sulfonylurea, DPP-4 inhibitor) if relevant
• Clinical rationale for GLP-1 class selection (cardiovascular risk, renal protection, weight comorbidity, hypoglycemia avoidance)
• Specific drug requested with strength, dosage form, and directions for use
• Continuation-of-therapy checkbox if patient is established on the requested GLP-1
• Brand override checkbox if requesting brand over generic where applicable
• Quantity-limit override checkbox and explanation if exceeding plan monthly quantity limits

8. Quantity-limit override pathway

The SD-specific GLP-1 Agonists PA Form includes a structured quantity-limit override section. Verbatim:

“Quantity limit requests: / What is the quantity requested per MONTH? _________ / What is the reason for exceeding the plan limitations? / ☐ Titration or loading dose purposes / ☐ Patient is on a dose-alternating schedule (e.g., one tablet in the morning and two tablets at night, one to two tablets at bedtime) / ☐ Requested strength/dose is not commercially available / ☐ Other: ___”

Practical use cases for the quantity-limit override:

• Titration / loading-dose purposes. Wegovy titration from 0.25 mg through 1.7 mg to 2.4 mg requires multiple monthly dose strengths during the 16-week titration window. The titration checkbox covers this scenario.
• Dose-alternating schedule. Some patients on oral semaglutide (Rybelsus) or oral orforglipron (Foundayo) require non-standard daily dosing schedules. The dose-alternating checkbox covers this.
• Requested strength/dose is not commercially available. Where the prescribed dose requires a combination of available strengths (e.g., a 1.25 mg Wegovy week-7 dose between the 1.0 mg and 1.7 mg labeled doses), the commercial-availability checkbox justifies the additional dispensing.
• Other. Free-text for any scenario not captured by the structured checkboxes.

9. Tribal health overlap: 9 federally recognized tribes

South Dakota has 9 federally recognized tribes. The Indian Health Service (IHS) and tribal facility utilization represents a meaningful share of total Medicaid utilization in South Dakota — comparable in proportional terms to Montana’s tribal overlap (Pattern #46) and somewhat less than the largest per-capita IHS Medicaid populations (Alaska, New Mexico, Arizona).

9.1 The 9 federally recognized tribes

• Cheyenne River Sioux Tribe (Cheyenne River Reservation)
• Crow Creek Sioux Tribe (Crow Creek Reservation)
• Flandreau Santee Sioux Tribe (Flandreau Indian Reservation)
• Lower Brule Sioux Tribe (Lower Brule Reservation)
• Oglala Sioux Tribe (Pine Ridge Indian Reservation)
• Rosebud Sioux Tribe (Rosebud Indian Reservation)
• Sisseton-Wahpeton Oyate (Lake Traverse Reservation)
• Standing Rock Sioux Tribe (Standing Rock Reservation — SD-ND border)
• Yankton Sioux Tribe (Yankton Reservation)

9.2 100% FMAP for IHS facilities

Services rendered to AI/AN Medicaid beneficiaries at IHS facilities (whether direct IHS, tribal 638-contract, or urban Indian) draw 100% Federal Medical Assistance Percentage — the state pays no share. Tribal members enrolled in Medicaid pay no premiums or copays.

9.3 The AOM exclusion still applies

Despite the 100% FMAP and zero-cost-share advantages for AI/AN Medicaid beneficiaries, the functional anti-obesity-medication exclusion still applies to drugs dispensed through IHS-Medicaid billing pathways. An SD Medicaid-enrolled AI/AN beneficiary at Pine Ridge, Standing Rock, Rosebud, or any urban Indian pharmacy faces the same OptumRx-administered GLP-1 PA pathway and the same T2D-only PA form scoping. The 100% FMAP advantage applies on the back end of the reimbursement flow but does not change the operational coverage criteria on the front end.

9.4 Tribal 638-contract pharmacy formulary access — UNVERIFIED

UNVERIFIED: Whether tribally operated 638-contract pharmacies have separate formulary access or AOM-coverage flexibility distinct from the SD Medicaid PA framework is not addressed in the publicly accessible SD Medicaid Pharmacy Services manual or in the SD DSS Pharmacy Provider page. Readers should contact the IHS Aberdeen Area Office or the relevant tribal health department for tribal-specific pharmacy benefit information.

10. Legislative context: no AOM-specific bills, expansion-focused 2025 session

No GLP-1- or AOM-specific Medicaid bills were identified in South Dakota Legislature 2024 or 2025 sessions. This is UNVERIFIED in the negative — direct fetch of sdlegislature.gov bill-listing pages returned browser-compatibility errors during verification on May 15, 2026, so a residual possibility exists that a relevant bill was filed but not surfaced via the direct fetch.

The 2025 South Dakota Legislative Session focused on Medicaid permanence and trigger questions rather than AOM coverage:

• HJR 5001 (referred Constitutional Amendment I to November 3, 2026 ballot, conditioning expansion on FMAP ≥ 90%). Passed House 59-7 (Jan 21, 2025) and Senate 31-3 (March 3, 2025). Senate sponsor Sen. Casey Crabtree (R).
• House proposal to repeal Medicaid expansion. Stopped by the House. This was a direct repeal proposal distinct from the trigger-architecture HJR 5001.

Sen. Boldman-style AOM-mandate bills (analogous to MT SB 417, ME LD 480, NE LB907, VT H.765/S.164) have not been filed in SD in the 2024-2025 sessions to the best of available verification. The legislative bandwidth in 2025 was consumed by the expansion-trigger architecture rather than AOM coverage policy.

10.1 Forthcoming PDL change (May 15, 2026): Physician-Administered-Drug biosimilars

A near-term SD Medicaid PDL change effective May 15, 2026 is announced via SD news brief:

“Beginning May 15, 2026, South Dakota Medicaid will implement a Preferred Drug List (PDL) for select Physician Administered Drugs with available biosimilars.”

This affects clinician-administered biosimilars — not the pharmacy-benefit GLP-1 class. The Physician-Administered-Drug PDL pertains to medical-benefit drugs (e.g., infused biologics with biosimilar competitors) rather than to retail pharmacy claims. GLP-1 agonists are dispensed through retail pharmacy under the FFS pharmacy benefit and are not affected by the May 15, 2026 PDL change.

UNVERIFIED: Specific details of the May 15, 2026 Physician-Administered-Drug biosimilar PDL announcement (effective date confirmation, drug classes affected, preferred biosimilar selections) are not fully extracted in this verification and should be confirmed via direct review of the SD Medicaid Pharmacy Provider page and OptumRx SDM portal.

11. Distinctive features: Pattern #45 vs. prior 44 states

South Dakota Pattern #45 occupies a distinctive place in the 50-state series along seven dimensions:

1. Ballot-initiative Medicaid expansion. SD is one of approximately 7 states that expanded by direct voter initiative (after ME 2017; ID/NE/UT 2018; MO/OK 2020; SD 2022). Effective July 1, 2023.
2. FFS-only architecture — no MCOs at all. Managed Care < 0.5% of spend (KFF May 2025). One of approximately 10 states without comprehensive MCOs. No MCO-internal appeals layer — denials go straight from OptumRx adjudication to DSS reconsideration to OAH fair hearing.
3. Small population, small enrollment. 125K-137K total enrollees; 28K-30K expansion. Among the smallest state Medicaid programs in the country — comparable in scale to North Dakota, Vermont, Wyoming, and Alaska.
4. Functional AOM exclusion by absence. No codified categorical AOM exclusion in the Pharmacy Services manual, but the OptumRx-administered SD-specific GLP-1 PA form pre-codes only T2D as the indication checkbox. Distinctive in the 50-state series: most exclusion states use explicit PDL/manual language; SD operates by operational silence.
5. Limited PDL architecture. Verbatim from manual page 5: “South Dakota Medicaid has a limited preferred drug list (PDL). … If a drug is not listed on the PDL that means it is not subject to the PDL. … All drugs, whether on the PDL or not, may be subject to prior authorization criteria (PA).” Different PDL architecture from most states — coverage gating runs primarily through PA criteria, not PDL preferred/non-preferred tiering.
6. Federal-funding-trigger Amendment I on November 3, 2026 ballot. If voter-approved and federal FMAP drops below 90%, expansion auto-sunsets. Structurally similar to trigger laws in MT, AZ, AR, IL, IN, IA, MI, NH, NM, NC, OH, UT, VA, WA but constitutionalized via ballot — a unique mechanism in the 50-state series.
7. Tribal health context. SD has 9 federally recognized tribes; IHS/tribal facility utilization meaningful share of Medicaid utilization. AOM exclusion still applies to drugs dispensed through IHS-Medicaid billing.

12. Cash-pay and manufacturer-program landscape for excluded indications

SD Medicaid beneficiaries who do not qualify for T2D-indicated GLP-1 coverage must rely on out-of-pocket and manufacturer-program pathways. The 2026-05-15 NovoCare and LillyDirect verifications produced the following operational landscape:

12.1 NovoCare Wegovy direct pricing (Novo Nordisk)

• 0.25 mg / 0.5 mg / 1.0 mg / 1.7 mg pen-injector: tiered cash-pay pricing $199-$349 per 28-day supply depending on dose. Verify current dose-specific pricing at novocare.com.
• HD (high-dose) pen-injector: $399 per 28-day supply.
• Oral semaglutide tablets (for CV indication): $149 per 30-day supply.
• Direct-to-home shipping: available to SD addresses. Verify with the manufacturer for rural-address coverage.

12.2 LillyDirect Zepbound and Foundayo direct pricing (Eli Lilly)

• Zepbound vials: $299-$699 per 28-day supply depending on dose (single-dose vials, self-administered).
• Foundayo (orforglipron) oral tablets: $149 per 30-day supply self-pay. Foundayo was FDA-approved April 1, 2026 and is the first FDA-approved oral non-peptide GLP-1 receptor agonist for chronic weight management.
• Mounjaro (T2D-only indication): LillyDirect cash-pay tiers available; coverage in SD Medicaid is via the T2D-indicated GLP-1 PA pathway.
• Direct-to-home shipping: available to SD addresses via lillydirect.lilly.com.

12.3 Manufacturer patient-assistance programs (income-tested)

• Novo Nordisk Patient Assistance Program (PAP): income-tested support for Wegovy, Saxenda, Victoza, Ozempic, Rybelsus, and other Novo Nordisk products. Application at novocare.com/patient-assistance-program.
• Lilly Cares Foundation: income-tested support for Zepbound, Mounjaro, Trulicity, and other Lilly products. Application at lillycares.com.
• Eligibility: PAPs typically require income at or below 300-400% FPL, no other insurance coverage for the requested drug, and US residency. SD Medicaid beneficiaries who do not qualify for Medicaid coverage of the requested drug may still qualify for PAP support; the manufacturer programs and Medicaid are coordinated to avoid duplication.

12.4 LegitScript-approved compounded telehealth

• Compounded semaglutide: typical market pricing $99-$199 per month as of May 2026 via LegitScript-approved telehealth platforms.
• Compounded tirzepatide: typical market pricing $149-$249 per month.
• FDA compounding-resolved status: FDA declared tirzepatide compounding-resolved in October 2024 and semaglutide compounding-resolved in February 2025. New compounded prescriptions for these molecules now require documented patient-specific clinical need beyond the previous shortage justification.
• LegitScript verification: only use LegitScript-approved (or equivalent third-party-verified) telehealth platforms. Unverified online pharmacies may dispense substandard or adulterated product; SD rural patients are at elevated risk given limited in-person dispensing options.

12.5 Total annual cash-pay cost calibration

For an SD Medicaid beneficiary who would otherwise be a GLP-1 obesity candidate, annual cash-pay costs (excluding office visits, lab work, and other ancillary care) calibrate as follows:

• NovoCare Wegovy 1.0 mg / 1.7 mg standard dose: $249-$349/month × 12 = $2,988-$4,188 annually.
• LillyDirect Zepbound 5 mg / 10 mg vial: $349-$549/month × 12 = $4,188-$6,588 annually.
• LillyDirect Foundayo (orforglipron) 6 mg / 12 mg / 36 mg tablet: $149/month × 12 = $1,788 annually.
• LegitScript-approved compounded semaglutide: $99-$199/month × 12 = $1,188-$2,388 annually.
• LegitScript-approved compounded tirzepatide: $149-$249/month × 12 = $1,788-$2,988 annually.

These costs are substantial for a Medicaid-eligible population (incomes by definition below 138% FPL for the expansion segment). The combination of small population, sparse-geography, and tribal-overlap means SD patients are particularly affected by the cash-pay cost barrier.

13. End-to-end prescriber workflow for SD Medicaid GLP-1 PA

For prescribers writing GLP-1 prescriptions for SD Medicaid beneficiaries, the operational workflow is:

1. Determine the indication and verify coverage gating.
   • T2D-indicated (Ozempic, Mounjaro, Trulicity, Victoza, Rybelsus, Exenatide): standard PA via OptumRx using the SD-specific GLP-1 Agonists PA Form. Document T2D diagnosis (ICD-10 E11.x), HbA1c, prior medication trials, and clinical rationale.
   • Obesity / CV / OSA / MASH / pediatric indications: no SD-specific carve-out criteria published. Call OptumRx at 1-855-401-4262 BEFORE submitting to verify whether the “Other diagnosis” line has operational coverage criteria. Submitting blind risks a denial that consumes the 30-day appeal clock.
   • Obesity-only without any FDA-label carve-out: functionally NOT COVERED. Refer the patient to manufacturer cash-pay (NovoCare, LillyDirect), patient assistance programs (Novo Nordisk PAP, Lilly Cares), or LegitScript-approved compounded telehealth.
2. Complete the SD-specific GLP-1 Agonists Prior Authorization Request Form. Available at contenthub-aem.optumrx.com. Document:
   • Patient name, Medicaid ID, date of birth
   • Prescriber NPI, contact information, signature
   • Medication name, strength, dosage form, directions for use
   • Brand override checkbox if applicable
   • Continuation-of-therapy checkbox if applicable
   • Indication checkbox: Type 2 diabetes mellitus (for T2D) or Other diagnosis with ICD-10 (for non-T2D, with prior verbal verification)
   • Quantity-limit override section if applicable
   • Free-text comments / clinical information field with full clinical justification
3. Fax to OptumRx at 1-844-403-1029. Mon-Sat 7am-7pm Central. For urgent or expedited requests, call 1-855-401-4262. Do NOT use the “copy-for-future-use” PA form — the form is updated frequently and may be barcoded; copying creates risk of using a stale or misread form.
4. Expect 72-hour adjudication; clean requests often < 24 hours. Per the SD Medicaid Pharmacy Services manual verbatim: “Most PA requests are adjudicated within 72 hours. A clean request is often adjudicated in less than 24 hours.”
5. For denials: call OptumRx at 1-855-401-4262 to verify denial rationale. Re-submit with stronger evidence if the denial is documentation-deficient. For substantive criteria-based denials, advise the beneficiary to file the administrative hearing request with the SD DSS Office of Administrative Hearings within 30 days of the denial notice. Explicitly request continuation of benefits at the time of hearing-request filing.
6. For provider-side billing-and-coding disputes (separate from clinical PA disputes): file provider reconsideration via the Medicaid Portal Communications tab within 6 months of date of service or 3 months of denial remittance.

Pharmacy claim adjudication: the OptumRx PA approval permits the pharmacy to submit a claim through the SD Medicaid pharmacy point-of-sale system. The pharmacy will receive an approval message keyed to the PA number; the beneficiary pays no copay for covered drugs under SD Medicaid (federal copay rules apply per 42 CFR 447.50-447.57). For AI/AN beneficiaries served by IHS or tribal 638 pharmacies, the same approval flow applies with 100% FMAP back to the state.

14. Patient scenario narratives

The following hypothetical scenarios illustrate how the SD Medicaid AOM exclusion-by-absence and the PA process operate in practice. These are illustrative scenarios, not specific patient cases.

14.1 Scenario: Established T2D patient on Ozempic

A 54-year-old SD Medicaid beneficiary in Sioux Falls with Type 2 diabetes (ICD-10 E11.9), HbA1c 8.4%, BMI 34, and established Ozempic 1 mg weekly for the past 18 months. Patient relocates from a state with positive coverage to SD. Workflow: patient’s new PCP submits the SD-specific GLP-1 Agonists Prior Authorization Request Form to OptumRx via fax 1-844-403-1029. The PA form documents the T2D diagnosis (checkbox), continuation-of-therapy (checkbox), and free-text clinical information field includes recent HbA1c, prior metformin trial outcome, current Ozempic dosing, and clinical rationale. OptumRx adjudicates the request — adjudication typically < 24 hours for a clean request, up to 72 hours for most requests. Approval is expected for T2D-indicated Ozempic use. Patient continues therapy without interruption. The functional AOM exclusion does NOT apply because the indication is T2D, not weight reduction.

14.2 Scenario: Patient with obesity but no T2D, no CVD, no OSA, no MASH

A 38-year-old SD Medicaid beneficiary in Rapid City with BMI 36, no Type 2 diabetes, no established cardiovascular disease, no sleep-study-documented OSA, no MASH. Patient wants Wegovy or Zepbound for weight management. Workflow: prescriber explains the functional AOM exclusion. The SD-specific GLP-1 Agonists PA Form does not offer an obesity/E66 ICD-10 pathway; the “Other diagnosis” line is theoretical but no published criterion confirms approval. Prescriber should call OptumRx at 1-855-401-4262 to verify any operational pathway before submitting; if no pathway is confirmed, Wegovy and Zepbound for obesity are functionally NOT covered. Practical alternatives: (1) NovoCare Wegovy cash-pay tiered pricing; (2) LillyDirect Zepbound vials cash-pay; (3) LillyDirect Foundayo (orforglipron, FDA-approved April 1, 2026) at $149/month self-pay; (4) Novo Nordisk PAP or Lilly Cares income-tested support; (5) LegitScript-approved compounded telehealth.

14.3 Scenario: Patient with established CVD and obesity, no T2D

A 62-year-old SD Medicaid beneficiary in Pierre with BMI 31, prior myocardial infarction (ICD-10 I25.2 documenting old MI), no Type 2 diabetes. Patient’s cardiologist proposes Wegovy for cardiovascular risk reduction under the SELECT-trial-derived indication. Workflow: prescriber calls OptumRx at 1-855-401-4262 to verify whether the “Other diagnosis” line has operational coverage criteria for Wegovy CV indication. If OptumRx confirms no SD-specific carve-out criteria are published, the prescriber should: (1) explain the cash-pay alternative pathways to the patient; (2) consider submitting an “Other diagnosis” PA with full clinical documentation of the CV indication (prior MI with cardiology consult notes, ECG, cath, MRI), BMI ≥ 27 threshold, absence of T2D, lifestyle counseling, and “not for weight loss only” attestation, recognizing that approval is not guaranteed; (3) advise the patient to file the OAH appeal within 30 days if the PA is denied.

14.4 Scenario: AI/AN Medicaid beneficiary at a tribal 638 pharmacy on Pine Ridge

A 45-year-old AI/AN Medicaid beneficiary served by a tribal 638-contract pharmacy on the Pine Ridge Indian Reservation. Patient has Type 2 diabetes and wants to start Mounjaro. Workflow: tribal pharmacy operates under the SD Medicaid pharmacy benefit (the 100% FMAP applies on the back end but the formulary on the front end is the SD Medicaid PA framework administered by OptumRx). The prescriber submits the standard SD-specific GLP-1 Agonists PA Form via OptumRx with T2D diagnosis. The patient pays no copay. The functional AOM exclusion does NOT apply because the indication is T2D. Whether 638-contract pharmacies have separate formulary access or AOM-coverage flexibility distinct from the SD Medicaid PA framework remains UNVERIFIED.

14.5 Scenario: PA denied, patient files OAH fair hearing

A 50-year-old SD Medicaid beneficiary’s T2D-indicated GLP-1 PA is denied by OptumRx on grounds that the prior metformin trial documentation is insufficient. Workflow: (1) prescriber calls OptumRx at 1-855-401-4262 to verify denial rationale; (2) prescriber re-submits the PA with additional documentation (metformin start date, dose, duration, HbA1c trajectory, adverse effects or intolerance); (3) if re-submission also denies, the patient files the administrative hearing request with the SD DSS Office of Administrative Hearings within 30 days of the denial notice; (4) hearing request is mailed to OAH at 700 Governors Drive, Pierre, SD 57501, with explicit request for continuation of benefits during the appeal; (5) the ALJ schedules the hearing; (6) the patient submits supporting exhibits at least 5 days before the hearing; (7) the ALJ issues a final decision within 90 days.

14.6 Scenario: Expansion adult with obesity facing Amendment I uncertainty

A 35-year-old SD Medicaid expansion enrollee (eligibility under Amendment D, July 2023) with BMI 38, no T2D, no CVD, no OSA. Patient wants Wegovy for chronic weight management. Workflow: prescriber explains (1) the functional AOM exclusion currently applies — Wegovy for obesity is not covered by SD Medicaid; (2) Constitutional Amendment I on the November 3, 2026 ballot would not change AOM coverage criteria but would condition continued expansion eligibility on FMAP ≥ 90% — meaning the patient’s Medicaid eligibility itself could change post-2026 election; (3) practical alternatives are cash-pay manufacturer programs, PAPs, or LegitScript-approved compounded telehealth. The patient’s policy advocacy is most productive if directed at SD DSS Division of Medical Services (to develop AOM PA criteria) and at the SD Legislature (to authorize and fund such coverage), recognizing the trigger-architecture overlay.

15. UNVERIFIED items — flagged honestly

Per Weight Loss Rankings’ YMYL 125% accuracy standard, the following items are flagged as UNVERIFIED rather than fabricated. These are gaps in the publicly available SD Medicaid primary sources that readers should verify independently:

1. No verbatim PDL/manual sentence stating “anti-obesity drugs are not covered.” The exclusion is operational, not codified. The SD Medicaid Pharmacy Services Billing & Policy Manual (December 2025) does not contain a categorical-exclusion sentence; the SD Medicaid Pharmacy Provider page does not enumerate a “Not Covered” bucket. Pattern #45 is distinctive in this respect among the 50-state series.
2. CV / OSA / MASH / pediatric carve-outs. No SD-specific guidance published. The PA form’s “Other diagnosis” line is a theoretical pathway, but no published criterion confirms approval. Prescribers should call OptumRx at 1-855-401-4262 before submitting non-T2D PAs.
3. Expedited fair-hearing timeline. The DSS Fair Hearings page does not document an SD-specific expedited pathway for Medicaid pharmacy denials. Federal floor (42 CFR § 431.224) requires expedited where life/health is jeopardized.
4. Continuation of benefits pending appeal. SD Medicaid Recipient Rights & Responsibilities page does not document. Federal regulations (42 CFR § 431.230 and § 431.231) require continuation where the beneficiary requests a hearing before the adverse-action effective date. SD-specific implementation is not transparent.
5. SD Legislature 2024-2025 GLP-1 / AOM-specific bills. Negative-result verification not fully confirmed via direct fetch — sdlegislature.gov bill-listing pages returned browser-compatibility errors during verification.
6. May 15, 2026 Physician-Administered-Drug biosimilar PDL announcement details. Effective date confirmation, drug classes affected, preferred biosimilar selections, and operative implementation specifics not fully extracted in this verification. Affects clinician-administered biosimilars only — not pharmacy-benefit GLP-1 class.
7. Tribal 638-contract pharmacy AOM-exclusion parity. Whether tribally operated 638-contract pharmacies have separate formulary access or AOM-coverage flexibility distinct from the SD Medicaid PA framework is not addressed in publicly accessible documents. Readers should contact the IHS Aberdeen Area Office or relevant tribal health departments.
8. OptumRx programmatic clinical criteria for SD Medicaid T2D-indicated GLP-1 review. The specific clinical criteria OptumRx applies beyond the T2D checkbox (HbA1c thresholds, step-therapy expectations, quantity limits) are not transparent in the SD-specific PA form or in the SD Medicaid Pharmacy Services manual.

If you encounter any of these gaps in practice — particularly publication of any SD-specific obesity-indication carve-out criteria — please contact us and we will update this article with verified primary-source language in a subsequent revision.

16. How South Dakota Pattern #45 fits the 50-state series

South Dakota (Pattern #45) occupies the “functional AOM exclusion by absence” cell in the taxonomy. The 45-state series to date documents the following coverage-architecture groups:

16.1 South Dakota vs. Montana (Pattern #46) — closest peer

Both SD Pattern #45 and MT Pattern #46 are functional AOM-exclusion states with no operationalized FDA-label carve-outs verified. Both are sparsely populated states with significant tribal health overlap. Both use FFS or FFS+PCCM architecture rather than capitated MCOs.

Distinctive differences:

• Exclusion mechanism: MT codifies the exclusion verbatim on the DPHHS Pharmacy Program page and in the Montana Medicaid Prescription Drug Program Manual (“The program explicitly does not reimburse for drugs prescribed for weight reduction”). SD has NO codified categorical sentence — the exclusion operates by absence and PA-form scoping.
• Architecture: MT operates FFS + PCCM (Passport to Health since 1993). SD operates FFS-only with no PCCM overlay.
• PA processor: MT uses Mountain-Pacific Quality Health (non-profit QIO). SD uses OptumRx (commercial PBM).
• 2025 legislative outcome: MT ran a clean WHO-vs-WHAT split (HB 245 made expansion permanent; SB 417 AOM mandate died 11-1). SD ran HJR 5001 (referring trigger-architecture Amendment I to ballot); no AOM-specific bill was filed.
• Trigger architecture: SD has Constitutional Amendment I on November 3, 2026 ballot — uniquely constitutionalized FMAP trigger. MT does not have a comparable trigger amendment.
• Appeals architecture: SD uses single-step (30 days to OAH; 90-day ALJ decision). MT uses two-step (15-day beneficiary window + 30+30+90 provider-side per Mont. Admin. R. 37.5.310).
• Continuation of benefits: MT codifies automatic opt-out continuation. SD’s continuation policy is UNVERIFIED.

16.2 South Dakota vs. Vermont (Pattern #41) — inverse architecture

SD and VT represent inverse architectures in the AOM-exclusion taxonomy:

• Exclusion codification depth: VT codifies the exclusion explicitly with verbatim PDL language and operationalizes three FDA-label carve-outs (Wegovy MACE + Wegovy MASH + Zepbound OSA) via drug-specific PA forms. SD has NO codified categorical sentence and NO operationalized carve-outs.
• PA processor: VT uses Optum (commercial PBM, acquired Change Healthcare 2022). SD uses OptumRx (commercial PBM, UnitedHealth Group subsidiary). Both use the same parent corporate family but with different state-specific contracts.
• PDL architecture: VT publishes one unified PDL. SD operates a “limited PDL” with coverage gating primarily through PA criteria rather than PDL preferred/non-preferred tiering.
• Legislative reform attempts: VT’s H.765 / S.164 (2024) AOM-mandate bills stalled with DVHA’s $75M annual fiscal estimate. SD has no comparable bill filed in 2024-2025.
• Expansion architecture: VT expanded via early ACA enactment (2014). SD expanded by ballot initiative (Amendment D 2022, effective July 1, 2023) with constitutionalized trigger (Amendment I on November 3, 2026 ballot).

16.3 South Dakota vs. Kansas (Pattern #43) — opposite coverage posture

SD and KS represent opposite coverage postures in the small-Medicaid-state cohort:

• Coverage stance: KS COVERS Wegovy + Zepbound for obesity under KanCare 3.0 with PA criteria and LOOSENED criteria in 2024-2025 (de-listed Wegovy + Zepbound from Table 4). SD has no obesity-coverage criteria published — functional exclusion by absence.
• Architecture: KS operates capitated MCO (KanCare 3.0 with Sunflower / UHC / Healthy Blue). SD operates FFS-only.
• Expansion status: KS is one of 10 remaining NON-expansion states. SD expanded by ballot initiative (Amendment D 2022).
• Legislative trajectory: KS HAWK Act HB 2375 (2025-2026) died in committee; SB 363 / HB 2731 OBBBA-driven Medicaid changes effective July 1, 2026 with no GLP-1 provisions. SD HJR 5001 referred Amendment I to ballot; no AOM-specific bill filed.

16.4 South Dakota vs. Rhode Island (Pattern #40) — opposite trajectory

SD and RI represent opposite trajectories:

• Current coverage: RI CURRENTLY covers Wegovy + Zepbound + Saxenda + Contrave — one of only 13 active-coverage states per KFF January 2026. SD does not cover any GLP-1 for obesity.
• Policy direction: RI Governor McKee’s FY2027 Executive Budget Item 028 proposes October 1, 2026 sunset of weight-loss GLP-1 benefit. SD has no sunset proposal because there is no existing coverage to sunset — the policy direction is “maintain status quo of functional exclusion.”
• Architecture: RI operates capitated MCO (NHPRI + UHC since July 1, 2025) with EOHHS FFS PDL as floor. SD operates FFS-only with OptumRx as pharmacy claims processor.
• Trigger architecture: SD’s Constitutional Amendment I (90% FMAP trigger) is uniquely constitutionalized. RI does not have a comparable expansion-trigger amendment.

17. What South Dakota Medicaid beneficiaries should do right now

If you have Type 2 diabetes: T2D-indicated GLP-1 receptor agonists are covered with PA via OptumRx. Ask your prescriber to submit the SD-specific GLP-1 Agonists Prior Authorization Request Form to OptumRx at fax 1-844-403-1029 (Mon-Sat 7am-7pm Central). Document the T2D diagnosis with ICD-10 (E11.x), baseline and recent HbA1c, prior metformin and second-line class trials, and the clinical rationale for GLP-1 selection. Adjudication is typically within 72 hours; clean requests often < 24 hours.

If you have an established CV / OSA / MASH indication: there is no SD-specific carve-out criterion published. Ask your prescriber to call OptumRx at 1-855-401-4262 BEFORE submitting any PA to verify whether the “Other diagnosis” line has operational coverage criteria for your specific indication. If OptumRx confirms no SD-specific carve-out criteria are published, consider whether to submit an “Other diagnosis” PA with full clinical documentation (recognizing approval is not guaranteed) or to pursue cash-pay alternatives.

If you do not have a T2D diagnosis or an established CV / OSA / MASH indication: SD Medicaid will not cover GLP-1 receptor agonists for obesity. Practical paths: (1) NovoCare Wegovy cash-pay ($199-$349/month depending on dose; HD pen at $399/month; oral semaglutide tablets at $149/month); (2) LillyDirect Zepbound vials at $299-$699/month; (3) LillyDirect Foundayo (orforglipron, FDA-approved April 1, 2026) at $149/month; (4) patient assistance programs (Novo Nordisk PAP, Lilly Cares) for income-tested support; (5) LegitScript-approved compounded telehealth at $99-$199/month for semaglutide and $149-$249/month for tirzepatide (with the FDA compounding-resolved caveat for both molecules).

If you are an AI/AN Medicaid beneficiary served by an IHS, tribal 638, or urban Indian pharmacy: the functional AOM exclusion still applies despite 100% FMAP. T2D-indicated coverage operates the same way as for non-AI/AN beneficiaries via OptumRx. For questions specific to tribal 638 pharmacies, contact the IHS Aberdeen Area Office or your tribal health department.

If your PA is denied: do not give up after the first denial. Call OptumRx at 1-855-401-4262 to verify denial rationale — many denials are documentation deficiencies recoverable via re-submission. If the denial is criteria-based, re-submit with stronger clinical evidence. If re-submission fails, file the fair-hearing request with the SD DSS Office of Administrative Hearings within 30 days. Mail or fax the request to OAH at 700 Governors Drive, Pierre, SD 57501; phone 605.773.6851; fax 605.773.6873; email admhrngs@state.sd.us. Explicitly request continuation of benefits at the time of hearing-request filing. Submit supporting exhibits at least 5 days before the hearing. The ALJ must issue a final decision within 90 days.

If you want to influence policy: the most productive paths are (1) advocacy directed at DSS Division of Medical Services to develop and publish AOM PA criteria (phone (605) 773-3165); (2) advocacy directed at the SD Legislature to authorize and fund obesity-indicated GLP-1 coverage in future biennial sessions; (3) public engagement on Constitutional Amendment I (November 3, 2026 ballot), recognizing that the trigger architecture is structurally distinct from AOM coverage policy but is the policy lever currently in play. Sen. Boldman-style AOM-mandate bills (analogous to MT SB 417 or ME LD 480) have not been filed in SD as of May 15, 2026; the 2027 session would be the next realistic window.

18. Key takeaways for South Dakota Medicaid GLP-1 access

1. The exclusion is operational, not codified. Pattern #45 is structurally distinctive in the 50-state series. The SD Medicaid Pharmacy Services Billing & Policy Manual (December 2025) does NOT contain a verbatim “anti-obesity drugs are not covered” sentence. The exclusion operates because the OptumRx-administered SD-specific GLP-1 Agonists PA Form pre-codes only T2D as the indication checkbox — with no obesity/E66 ICD-10 pathway offered. Functional AOM exclusion by absence.
2. FFS-only architecture, no MCOs. Managed Care < 0.5% (KFF May 2025). One of approximately 10 states without comprehensive Medicaid managed care. No MCO-internal appeals layer — one-step appeals architecture from OptumRx adjudication to OAH fair hearing.
3. OptumRx is the pharmacy claims processor since November 13, 2017. PA fax 1-844-403-1029; urgent phone 1-855-401-4262. Commercial PBM subsidiary of UnitedHealth Group.
4. Limited PDL architecture. Coverage gating runs primarily through PA criteria rather than PDL preferred/non-preferred tiering. Verbatim: “If a drug is not listed on the PDL that means it is not subject to the PDL.”
5. Ballot-initiative Medicaid expansion + uniquely constitutionalized FMAP trigger. Amendment D approved November 8, 2022 (56.21% yes) effective July 1, 2023. HJR 5001 referred Constitutional Amendment I to the November 3, 2026 ballot — would condition expansion on FMAP ≥ 90%. Passed House 59-7 (Jan 21, 2025) and Senate 31-3 (March 3, 2025).
6. PA turnaround verbatim: “Most PA requests are adjudicated within 72 hours. A clean request is often adjudicated in less than 24 hours.” One-year PA end date; no backdating; 5-day emergency fill where delay would harm patient care; 34-day day-supply cap; $5,000 high-dollar PA threshold.
7. Appeals architecture is single-step with tight beneficiary window. 30 days to file with OAH (700 Governors Drive, Pierre, SD 57501; phone 605.773.6851); ALJ must issue final decision within 90 days; exhibits due 5 days before hearing. Expedited pathway and continuation of benefits both UNVERIFIED.
8. 9 federally recognized tribes; meaningful IHS overlap. Cheyenne River, Crow Creek, Flandreau Santee, Lower Brule, Oglala (Pine Ridge), Rosebud, Sisseton-Wahpeton Oyate, Standing Rock, Yankton. 100% FMAP at IHS facilities but functional AOM exclusion still applies.
9. Small Medicaid program. 125K-137K total enrollees; 28K-30K expansion enrollees. Among the smallest state Medicaid programs in the country — comparable in scale to North Dakota, Vermont, Wyoming, and Alaska.
10. CV / OSA / MASH / pediatric carve-outs UNVERIFIED. No SD-specific guidance published. The PA form’s “Other diagnosis” line is theoretical; prescribers should call OptumRx at 1-855-401-4262 before submitting non-T2D PAs.

Related coverage

• Hawaii Med-QUEST GLP-1 Coverage (Pattern #50 CAPSTONE / SERIES COMPLETE) — opposite codification architecture in the categorical-exclusion cohort: where SD operates a functional AOM exclusion by ABSENCE (no codified categorical sentence in the SD Medicaid Pharmacy Services Billing & Policy Manual; the OptumRx SD-specific GLP-1 PA form pre-codes ONLY T2D as the indication checkbox), HI codifies the exclusion VERBATIM at the AlohaCare formulary level: “Drugs for weight loss, erectile dysfunction, infertility, and cosmetic purposes are not covered.” SD is FFS-only under DSS Division of Medical Services; HI operates 5-MCO mandatory managed care under 32-year continuous 1115 demonstration (CMS 11-W-00001/9 since August 1, 1994 — longest in series). SD ballot-initiative expansion (2022 Amendment D); HI ACA expansion via standard 138% FPL. SD has no AOM-mandate bills in 2024-2025; HI SB 3195 (Sen. Kurt Fevella R, bipartisan, 2026 Regular Session) remains live. Pattern #50 closes the 50-state series
• Alaska Medicaid GLP-1 Coverage (Pattern #49) — closest peer in the “exclusion by absence” architectural subgroup: both SD and AK operate functional AOM exclusion by absence rather than codified categorical sentence, both are FFS-only states with no comprehensive MCOs; SD operates at the PA-form-pre-coding level (OptumRx SD-specific GLP-1 form pre-codes T2D only as the indication checkbox), AK operates at the PDL-listing level (Wegovy / Zepbound / Saxenda simply not on the formulary in any class; single General PA Form covers all classes with no drug-specific GLP-1 PA form); SD uses OptumRx (since November 13, 2017) while AK uses Prime Therapeutics Medicaid Administration (formerly Magellan Rx); both 30-day appeal windows to OAH with 90-day ALJ resolution; SD expanded via 2022 ballot Amendment D (56.21% yes) with Constitutional Amendment I (90% FMAP trigger) on the November 3, 2026 ballot, AK expanded via Gov. Walker executive action September 1, 2015; AK has 229+ federally recognized tribes (vs. SD’s 9) with 100% FMAP Tribal Health Compact through Alaska Area IHS + ANTHC
• Wyoming Medicaid GLP-1 Coverage (Pattern #47) — closest OptumRx-PBM peer (both SD and WY use OptumRx for pharmacy claims processing) and closest small-Medicaid-state peer (WY ~59,714 vs. SD 125-137K enrollment): WY codifies the exclusion explicitly (“Anorexiant products” in WDH Pharmacy Services Manual Revision 27 page 8) and codifies three FDA-label carve-ins (Wegovy SELECT/CV, Wegovy MASH, Zepbound OSA — LEAST restrictive OSA carve-in in categorical cohort, no CPAP prerequisite); SD operates a functional exclusion by ABSENCE with NO codified carve-ins. WY non-expansion (2026 expansion defeated 7-23 and 5-26); SD expanded via 2022 ballot Amendment D with HJR 5001 referring Constitutional Amendment I (90% FMAP trigger) to the Nov 3, 2026 ballot. WY uses FFS-only with WYhealth CME (not capitated); SD uses FFS-only with no comprehensive MCOs. WY had OptumRx pharmacy-benefit migration eff. April 15, 2026; SD has used OptumRx since November 13, 2017
• Montana Medicaid GLP-1 Coverage (Pattern #46) — closest peer in the 50-state series: also functional AOM-exclusion state with no operationalized carve-outs verified, sparsely populated, significant tribal health overlap, FFS+PCCM architecture — but MT codifies the exclusion verbatim while SD operates by operational silence
• Idaho Medicaid GLP-1 Coverage (Pattern #48) — closest operational-exclusion peer to SD: both ID and SD lack codified categorical AOM exclusion sentences and operate the exclusion through non-codification. ID codifies via IDAPA 16.03.09.662 SILENCE on anti-obesity drugs (rule lists fertility / cosmetic / cough-cold / ED but NOT AOMs); SD codifies via OptumRx GLP-1 PA form pre-coding only T2D as the indication checkbox. Both are ballot-initiative expansion states (ID Proposition 2 Nov 2018 ~60.6%; SD Amendment D Nov 2022 56.21%). ID delivery is FFS-dominant with IMPlus + MMCP duals-only MCO overlay (Molina + UnitedHealthcare); SD is FFS-only. ID PBM Prime Therapeutics 24-hour PA adjudication; SD PBM OptumRx 72-hour PA adjudication. ID appeals 28 days to neutral / independent OAH; SD appeals 30 days to OAH. ID active legislative repeal trajectory (HB 138 / HB 345 / HB 913); SD constitutional sunset trigger via Amendment I on November 3, 2026 ballot
• Kansas Medicaid GLP-1 Coverage (Pattern #43) — opposite coverage posture in the small-Medicaid-state cohort: KS COVERS Wegovy + Zepbound for obesity under KanCare 3.0 and LOOSENED criteria 2024-2025 (de-listed both drugs from Table 4)
• Delaware Medicaid GLP-1 Coverage (Pattern #42) — positive-coverage stable state with unified DMAP PDL across 3 MCOs (Wegovy + Saxenda preferred; Zepbound clinical-exception pathway); §1115 Diamond State Health Plan extended through December 31, 2028
• Vermont Medicaid GLP-1 Coverage (Pattern #41) — inverse architecture: categorical AOM exclusion bundled (weight-loss + fertility + cosmetic + hair-growth) with three operationalized FDA-label carve-outs (Wegovy MACE + Wegovy MASH + Zepbound OSA) under FFS-only Optum-administered pharmacy benefit
• Rhode Island Medicaid GLP-1 Coverage (Pattern #40) — opposite trajectory: active coverage with governor-proposed October 1, 2026 sunset (Wegovy + Zepbound + Saxenda + Contrave currently covered)
• Maine MaineCare GLP-1 Coverage (Pattern #39) — categorical exclusion with NO Wegovy MASH carve-out; LD 480 killed March 20, 2025
• Nebraska Medicaid GLP-1 Coverage (Pattern #38) — categorical exclusion with 45-74 age gate + 6-month MASH prerequisite; LB907 Indefinitely Postponed
• Utah Medicaid GLP-1 Coverage (Pattern #37) — legislative pilot-program coverage with 6/30/2026 sunset of in-lab attended PSG carve-out
• West Virginia Medicaid GLP-1 Coverage (Pattern #36) — categorical exclusion with Wegovy CV + Zepbound OSA + Wegovy MASH carve-outs via WVU RDTP
• Mississippi Medicaid GLP-1 Coverage (Pattern #35) — only non-expansion southern positive-coverage state; SPA 23-0013 carve-back-in with pediatric ages 12+ pathway
• 50-state Medicaid GLP-1 coverage map — full series overview with pattern taxonomy
• GLP-1 insurance coverage hub — Medicare, Medicaid, and commercial coverage landscape
• GLP-1 insurance dropped coverage appeal playbook — denial-recovery patterns applicable across states

Primary sources

1. SD Medicaid Pharmacy Services Billing & Policy Manual (updated December 2025) — PDL architecture, 72-hour PA turnaround, 5-day emergency fill, 34-day day-supply cap, $5,000 high-dollar PA
2. SD Medicaid GLP-1 Agonists Prior Authorization Request Form — footer ID GLP1Agonists_SouthDakotaMedicaid_2026May (May 2026 revision); T2D-only diagnosis checkbox
3. SD Medicaid Pharmacy Services Provider page — OptumRx pharmacy claims processor effective November 13, 2017
4. SD Medicaid Reconsideration Reviews, Coverage Requests, and Fair Hearings Manual (Feb 2025) — 30-day OAH filing window; 90-day ALJ decision; 5-day evidence rule
5. SD Medicaid Recipient Rights & Responsibilities
6. SD DSS Office of Administrative Hearings (OAH) Fair Hearings — 700 Governors Drive, Pierre, SD 57501; phone 605.773.6851; fax 605.773.6873; email admhrngs@state.sd.us
7. SD DSS — How to Request a Fair Hearing
8. SD Medicaid State Plan
9. SD DSS Economic Assistance Medical Programs
10. OptumRx SD Medicaid PDL portal
11. OptumRx SDM general site
12. KFF — Medicaid Coverage of and Spending on GLP-1s (Jan 16, 2026)
13. KFF Medicaid in South Dakota fact sheet (May 2025)
14. KFF South Dakota Medicaid & CHIP Indicators
15. Medicaid.gov Enrollment & Unwinding (October 2025)
16. Ballotpedia — SD Constitutional Amendment I (2026)
17. Ballotpedia News — HJR 5001 referral (March 5, 2025)
18. SD Legislature 2025 session bills
19. The Rx Index — Medicaid GLP-1 Coverage by State
20. Stateline — States retreat from covering drugs for weight loss (Nov 28, 2025)
21. healthinsurance.org — Medicaid eligibility and enrollment in South Dakota