The Colorado Medical Assistance Program offers a pharmacy program for drugs that are medically necessary, approved by the Food and Drug Administration, and made by pharmaceutical companies who participate in the federal rebate program. This program immensely helps those who are in need of medication and enrolled in Medicaid. If you have a condition that requires medication, it is especially helpful to enroll in the pharmacy program.
Certain prescriptions, such as diabetes supplies, are not covered. Test strips, lancets, and syringes are covered under Medicaid and not considered a pharmacy benefit. If you have MA, you will already have such coverage. Additionally, over-the-counter medications are partially covered. Insulin and aspirin are covered without any pre-authorization, while all OTCs need a doctor’s approval before they can be covered, unless they are on the formulary. Smoking cessation products are also covered with prior authorization. Some prescription coverage will be denied if a member has not received prior authorization for a certain drug. To avoid this, consult with your doctor, and ask that they contact Colorado Medicaid to request approval. The request will take up to 24 hours to process once it has been received.
Generics cost a copay of $1.00 through the pharmacy program, and $3.00 for brand names. Members up to age 18, living in a nursing home, or women on maternity coverage do not have any copays.
If you need a medication earlier than your prescribed refill date, it may only be covered when there is a dosage increase or if a member is going into or being dismissed from a nursing facility. Members can receive up to a 100 day supply of maintenance medications and up to a 30 day supply of non-maintenance prescriptions. If you run out of medication, speak with your doctor about tailoring your prescription to your current needs.
Brand Name Medication
If you wish to take the brand name version of a drug for which there is a generic substitute, Colorado Medicaid will not cover it unless your doctor prefers you take the brand over the generic. As the FDA approves all generics to be safe and plausible alternatives for brand names, Medicaid prefers to cover generics. Colorado Medicaid will pay for a brand name drug if the generic version is not available, or if it has been excluded from the generic mandate: medications for cancer, epilepsy, mental illness, and HIV/AIDS.
Lost or Stolen Medications
If your medication has been lost, stolen, or damaged, Colorado Medicaid will pay for one supply per lifetime for every member. Members who have had their medications stolen must send a copy of the police report that accompanies the case in order to be approved. To receive help with your case anbd coverage, call the Department of Health Care and Policy Financing (HCPF) at 303-866-3588 or 800-221-3943 ext. 3588.
Dual Eligible Coverage
Those who are enrolled in both Medicaid and Medicare will have their prescriptions covered through Medicare Part D. Though not all medications are covered, Colorado Medicaid will pay for a small number of drugs that Part D does not include. For more details on prescription coverage for Medicaid-Medicare members with Part D, call 888-696-7213 or 303-894-2946.