All Medicaid beneficiaries are eligible for prescription drug coverage. Colorado has implemented a preferred drug list (PDL), a formulary that establishes what drugs are covered and for what purposes. Some drugs are excluded from the PDL or require prior authorization. These include agents for anorexia/weight gain, fertility, cosmetics or hair growth, symptomatic cough/cold relief, smoking cessation, prescription vitamins and minerals, non-prescription drugs, less-than-effective drugs, barbiturates, benzodiazepines and over-the-counter drugs (except aspirin and insulin).
The PDL also has a generics preference, meaning that it will only cover generics, except if a generic is not available, if the doctor considers the name-brand to be medically necessary or if the medication is excluded from the generics preference (e.g. medications for mental illnesses, cancer, epilepsy and HIV/AIDS).
Beneficiaries will have to pay a $1.00 co-pay on generic drugs, $3.00 on brand-name drugs. Beneficiaries under 18, in nursing homes, in a maternity cycle or 60-days post-partum do not have a co-payment.
Limitations on coverage
Medicaid cannot pay for early refills, unless the individual is entering or leaving a nursing home (up to 100 days for maintenance medications or 30 days for non-maintenance).
Some drugs may require a prior authorization. This must be filed by the prescribing doctor. He/she can contact Medicaid at 1-800-365-4944 to request the form. Individuals who are not able to obtain a prescription due to prior authorization may request a 72-hour supply while authorization is obtained. The dispensing pharmacy will be reimbursed for making a 72-hour supply available.
Prescriptions may be ordered by mail, if the individual has a physical hardship that prevents them from using a local pharmacy or has third party insurance that requires them to use the a mail order pharmacy to obtain maintenance medications. Individuals or their physicians must enroll in the mail-order program in order to be covered.
Individuals on Medicare
Medicare beneficiaries are eligible for prescription drug coverage through Medicare Part D. Medicaid prescription drug coverage is not considered creditable coverage and therefore does not exempt the individual from having Part D coverage. Part D should be covering most if not all of the individuals drugs. Medicaid will only pay for a few medications excluded by the Part D plan. In general, Medicare beneficiaries will primarily use the Part D benefit, except for benzodiazaphines and barbiturates. Dual eligibles may be able to receive assistance with their prescription costs from the Low Income Subsidy (Extra Help).
The PDL is updated regularly and should be re-checked often. The Department of Health Care Policy and Financing posts the most recent PDL here.
Low income individuals who have difficulty paying for prescriptions may be eligible for free prescriptions through the Partnership for Prescription Assistance (PPARx) which makes drugs from the manufactuers available for free.
If you have any questions, please call us at 303-333-3482.