South Dakota program
Deadlines for treatment approval and drug exceptions
South Dakota sets deadlines for some health-plan decisions about treatment and trying another drug first.
What it is
South Dakota sets deadlines for some health-plan decisions about treatment and trying another drug first.
Waiting for a plan decision can delay treatment. South Dakota sets different clocks for treatment review and exceptions to trying another drug first. The plan type and whether the request is complete both matter.
Eligibility rules
- These state rules apply to health carriers performing utilization review and their designees.
- An urgent treatment request must be answered within 24 hours once it is complete. A request to skip a "try this drug first" rule gets five days, or 72 hours when urgent, and if the plan misses that deadline the exception is granted.
What you get
- A 24-hour decision deadline for a complete urgent treatment request under the state rule.
- A 72-hour urgent deadline for an exception to trying another drug first.
- A drug-step exception is granted automatically if its applicable deadline is missed.
What the help includes
- A routine request is decided within 15 days, which the plan can extend once by 15 days if it tells you why. If something is missing, the plan must say what within 24 hours for an urgent request, and the clock pauses while the clinic sends it.
- A timely request to extend qualifying urgent ongoing care has a separate 24-hour response rule when made at least 24 hours before the existing approval expires. These treatment clocks differ from the five-calendar-day ordinary and 72-hour urgent drug-step exception clocks.
If you decide to apply
- If a decision is delayed, ask the clinic for the date and time it sent the request and whether it marked it urgent.
- Ask the doctor whether a drug-step exception is appropriate and whether the plan has all required records.
- Bring the request history to the plan or Division of Insurance with the social worker’s help.
South Dakota Division of Insurance: 605-773-3563 · Official page ↗
After you ask
- The clinic supplies the medical request. The doctor supports any urgent designation or step-therapy exception.
Good to know
The 24-hour and 72-hour clocks cover different requests. A request for more information can affect the clock.
Other details
- The 2026 annual-review provisions expressly exclude drugs and prescription supplies. They should not be confused with the drug-step deadlines.
- The insurer annual-review duty took effect July 1, 2026 under the regular-session effective-date rule. An 80% approval threshold affects justification for retaining a requirement. Drugs, prescription supplies and specified dental coverage are excluded. This is insurer oversight, not a deadline for an individual treatment request or a first-report deadline on that date.
Official sources
“If approval is holding up treatment, which deadline applies to our plan? What are the benefits and drawbacks of an urgent review or drug exception, and could you help us pursue the right one?”
Why I’m asking: I want to know whether the plan has the full request and when a decision is due.
More background and detailed requirements
Additional program information and published rules
Who does what
The three parts, side by side. The agency decides; nobody on this page does.
You
Get the date and time the request went in, and call when the clock passes.
Your social worker
The clinic sends the request and the clinical documentation.
The care team
The doctor marks a request urgent and supports a step therapy override.
- Who decides
- The health plan
- Ask the care team
- “When did this go to the plan, was it marked urgent, and can you file a step therapy override if they want a different drug first?”
How to apply
First step: Ask the clinic for the date and time the request was sent.
- Ask the clinic for the date and time the request was sent.
- If it is urgent and more than 24 hours have passed, call the plan and name the deadline.
- If a cheaper drug is being demanded first, ask the doctor to file a step therapy override.
Official application / program page ↗
Where it starts: Ask the oncology team what date and time the request went in, then hold the plan to the clock.
What to gather
- The date and time the request went in
- Anything the plan has asked for since
How long: 24 hours urgent, 15 days standard, 72 hours for an urgent override.
What a yes looks like
An approval inside the deadline, or an override deemed granted because the plan did not answer.
What a no looks like, and the next move
Ask what evidence would meet the override grounds, and then use the outside review route.
Watch out
- The clock restarts when the plan asks for more information.
- Whether these clocks reach a self-funded or teacher plan was not established; ask HR.
- The 2026 annual-review duty expressly leaves out drugs.
Dates that change this
2026-09-11: The insurer annual-review duty took effect July 1, 2026 under the regular-session default rule. Its 80% approval threshold affects justification for retaining a requirement. Drugs, prescription supplies and specified dental coverage are excluded. This is not an individual request deadline or a first-report deadline on that date. (not yet confirmed against the final rule)
The numbers and the rules
The arcane layer, kept on purpose. Checked September 11, 2026.
What it is worth
24 hours for an urgent approval, 15 days otherwise, and a step therapy override granted automatically if the plan misses its deadline.
- $24 — Urgent initial utilisation review decision
- $15 — Standard prospective review decision, extendable once by 15 days
- $72 — Urgent step therapy override decision
- $5 — Ordinary step therapy override decision after complete documentation
Legal protection: A step therapy override is deemed granted if the plan fails to answer in time · Treatment already certified continues without cost to you until the internal review decision is notified · An override must be approved where the required drug is contraindicated, is expected to be ineffective, has already failed, or the child is doing well on the chosen drug
What it costs the family: Nothing.
The eligibility facts, as published
- Plan type condition
- health carriers that provide or perform utilisation review and their designees; the plan-sponsor matrix for self-funded, teacher, city and Marketplace plans was not established
Expect friction on: The clocks only run once the plan has everything it asked for, so a missing note restarts them
The trap: Treatment requests and drug-step exceptions have different missing-information rules. A missed step-exception deadline grants that exception, not every requested treatment.
Where I read this
- SDCL chapter 58-17H — Health benefit plans — South Dakota Legislature, read September 10, 2026
- External Review, Health Insurance and Major Medical — South Dakota Division of Insurance, read September 10, 2026