S.D. Admin. R. 67:16:14:05

Current through Register Vol. 51, page 67, December 16, 2024

Section 67:16:14:05 - Items and services not covered

In addition to the items and services not specifically listed in § 67:16:14:04, the following items and services are not covered under this chapter:

(1) Nonlegend prescription drugs and over-the-counter items and medical supplies except for those items covered under § 67:16:14:04;

(2) Medical supplies or delivery charges;

(3) Legend oral vitamins except for legend vitamins prescribed for the prenatal care of pregnant women covered under § 67:16:14:04;

(4) Nicotine patches and other nicotine replacement products;

(5) Agents to promote fertility or treat impotence;

(6) Agents used for cosmetic purposes;

(7) Hair growth products;

(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;

(9) Items which exceed a 34-day supply, except for 90 day fills on select generic maintenance medications, family planning items, and prenatal vitamins;

(10) Services, procedures, or drugs which are considered experimental, 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;

(11) Drugs and biologicals which 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

(12) Drugs that did not receive prior authorization from the department under the provisions of this chapter.

S.D. Admin. R. 67:16:14:05

SL 1975, ch 16; 47 SDR 129, effective 6/3/2021; 48 SDR 39, effective 10/3/2021

General Authority: SDCL 28-6-1(1)(2).

Law Implemented: SDCL 28-6-1.

Reimbursement for prescribed drugs -- Signed rebate agreement required, Pub. L. No. 101-508, § 4401. Information about drugs which 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. A list of drugs that require prior approval is available at https://prdgov-rxadmin.optum.com/rxadmin/SDM/Prior_authorization.html.