South Dakota Medicaid and GLP-1 coverage

The drug list settles it in the class heading. Under the PDL 2026 tab the therapeutic category reads "ANTIDIABETICS GLP-1 RECEPTOR AGONISTS **No coverage for weight loss," and its preferred drugs are listed as "MOUNJARO," "OZEMPIC," "RYBELSUS," "TRULICITY," "VICTOZA," "WEGOVY (MACE or MASH only)" and "ZEPBOUND (OSA only)." There is no anti-obesity or weight-management class anywhere on the list: all 32 therapeutic categories on the 2026 tab were read on 2026-09-03 and none names obesity or weight. The list also states its own limits — "If a drug class is not included on the PDL at all, it is not subject to PDL requirements; however, medications in that class may still be subject to PA." The same list is published for readers on the program's own drug-list page, which draws it from the document cited here.

South Dakota Medicaid pharmacy program (OptumRx), Preferred Drug List, PDL 2026 · source

The exclusion is in the billing manual, in a list of things the program will not pay for. Under "NON-COVERED PRODUCTS OR SERVICES," South Dakota Medicaid states that "the following items and services are not covered," and the seventh bullet reads: "Agents used for anorexia, weight loss, weight gain, hair growth or cosmetic purposes." The same chapter notes that "South Dakota Medicaid has a limited preferred drug list (PDL)," that "If a drug is not listed on the PDL that means it is not subject to the PDL," and that "All drugs, whether on the PDL or not, may be subject to prior authorization criteria." Every page is stamped "UPDATED May 26."

South Dakota Department of Social Services, Medicaid Billing and Policy Manual — Pharmacy Services, effective May 2026 · source

The Wegovy form prints the refusal above the criteria. Its diagnosis block offers exactly two boxes — "Reduce the risk of major adverse cardiovascular event (MACE) without diabetes" and "Noncirrhotic metabolic dysfunction-associated steatohepatitis without diabetes" — followed by the line "Not covered for obesity or weight management or Type 2 diabetes mellitus." The cardiovascular route asks whether the patient has "established cardiovascular disease as evidenced by one of the following": prior myocardial infarction, prior stroke, or peripheral arterial disease, and asks for an HbA1c "within the last 2 months" and a BMI "to one decimal place." The MASH route asks whether "the patient's fibrosis stage F2 or F3," whether there is decompensated cirrhosis, and for a named specialist. Wegovy tablets require "a 90-day trial and failure of Rybelsus tablet." The form's own footer reads "Wegovy_SouthDakotaMedicaid_2026April."

South Dakota Medicaid, Wegovy Prior Authorization Request Form, effective April 2026 · source

Zepbound has its own form and one door on it. The diagnosis block offers "Moderate to severe obstructive sleep apnea (OSA)" and then repeats the same sentence: "Not covered for obesity or weight management or Type 2 diabetes mellitus." It asks for the BMI to one decimal place, whether "the patient's OSA confirmed via sleep study" and "the respiratory events per hour result from the sleep study," whether the patient is "participating in a supervised weight management plan that encourages behavioral medication, reduced calorie diet, and increased physical activity," and whether there is a "personal or immediate family history of medullary thyroid carcinoma or multiple endocrine neoplasia type 2 (MEN2)." The footer reads "Zepbound for OSA_SouthDakotaMedicaid_2026May."

South Dakota Medicaid, Zepbound for OSA Prior Authorization Request Form, effective May 2026 · source

South Dakota publishes what happens to these requests, which is rare. Its June 26, 2026 Pharmacy and Therapeutics Committee packet reports first-quarter 2026 prior authorization activity by class: the class labeled "ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREX" recorded 409 approved and 170 denied out of 579 requests — a 70.64% approval rate, 8.82% of all requests — and the packet names WEGOVY as the most requested product in it. The same packet's appeals detail lists WEGOVY at 1 approved and 3 denied out of 4, a 25.00% approval rate, against an all-drug appeal approval rate of 71.55% for the quarter. The packet's minutes separately record that on the MASH review a member "made motion to add criteria for trial and failure of Wegovy before Rezdiffra for patients with BMI 27 and over" and that the motion "was approved unanimously," and that on "Zepbound OSA" a member "motioned to adopt PA criteria" and "The motion passed unanimously."

South Dakota Department of Social Services, Medicaid P&T Committee Meeting packet, June 26, 2026, effective June 2026 · source

South Dakota gives you thirty days and runs the clock from the notice. The rule setting time limits provides that a hearing must be requested within "Thirty days after notice of the action complained of or the conference decision, or thirty days after action should have been taken by the department as provided by law or rule." The request goes to the department's Office of Administrative Hearings, and the companion rule allows it in writing or by speaking: for "the medical assistance program, an individual, or the individual's representative, shall submit a written or oral request for an appeal to the department's Office of Administrative Hearings." The rule's source note records its most recent amendment as effective September 29, 2025. The department's own hearings guide adds that for a Medicaid case "the decision must be mailed to the parties involved within ninety days from the date of the request for the hearing."

ARSD 67:17:02:04 and 67:17:02:03, Administrative Rules of South Dakota, read through the South Dakota Legislature's rules service, effective September 2025 · source