PA Forms

Effective November 13, 2017, all pharmacy related calls (to include prior authorizations) will be handled by OptumRx. Member and eligibility questions will continue to be answered by South Dakota Medicaid.  The contact information for OptumRx is listed below:

• Help Desk:                                                     (855) 401-4262                       Optum Rx
• FFS Pharmacy Prior Authorization support:     (855) 401-4262                       Optum Rx
• FFS Pharmacy Prior Auth. Fax Number:           (800) 527-0531                       Optum Rx 

All of the forms are in .pdf format. You must have Adobe Acrobat Reader to view the forms. If you do not have Adobe Acrobat Reader, we recommend downloading and installing the latest version.

• Adult GH PA
• Akynzeo Form
• Altabax Form
• Ambien CR Form
• Ampyra Form
• Amrix / Fexmid Form
• Antidepressant Form
• Antiemetics Form
• Antipsychotic Form
• Antipsychotic and Antidepressant Provider Letter
• Anti-Histamine
• ARBS
• Aubagio
• Brisdelle Forms
• Calomist and Nascobal Form
• Chronic Constipation Form
• Daklinza Form
• DAW
• Desoxyn Form
• Diclegis Form
• Dificid
• Durlaza Form
• Emflaza Form
• Epclusa Form
• Evzio Form
• Extavia Form
• General PA Form
• Genitourinary Smooth Muscle Relaxants
• Gilenya Form
• GLP-1 Form
• Gralise
• Harvoni
• Head Lice Medication Form
• Hemangeol Form
• Hetlioz Form
• Horizant
• Hydrocodone/APAP Form
• Immunomodolators Form
• IPF Form
• Lidoderm
• Luzu Form
• Lyrica Form
• Max Units Overide Form
• Medications greater than $5,000 PA Form
• MedWatch Form (Form FDA 3500)
• Methadone Form
• Metozolv Form
• Moxatag Form
• Name-Brand Narcotics Form
• Nasal Steroids
• Nexiclon
• Novantrone Form
• Nucala Form
• Nucynta Form
• Nuplazid Form
• Nuvessa Form
• Pediatric GH PA
• Proton Pump Inhibitors
• Provigil/Nuvigil Form
• Olysio Form
• Onfi
• Onychomycosis Form
• Onzetra Form
• Ophthalmic Antihistamines
• Oracea and Solodyn Form
• Oral Allergen Extracts Form
• Oral Anticoagolants
• Orkambi Form
• Oravig Form
• Otezla Form
• Otrexup Form
• PCSK9 Form
• Qualaquin Form
• Rayos
• Relistor
• Soma 250 Form
• Sovaldi Form
• Suboxone/Subetex Form
• Technivie Form
• Tivorbex Form
• Topical Acne Agents
• Topical Ketoconazole Products Form  
• Triptans Form
• Tysabri Form
• Uloric Form
• Ultram ER Form
• Viberzi Form
• Viekira Form
• Vusion Form
• Xeljanz Form
• Xenazine Form
• Xifaxan
• Xolair Form
• Xyrem Form
• Zepatier Form