Health First Colorado Pharmacy Benefits Frequently Asked Questions

Select over-the-counter (OTC) medications are covered. For an up-to-date list of covered OTC medications, go to Pharmacy Resources: Appendix P and search for the “OTC Products” section. You can also ask your provider or your pharmacist what OTC medications are covered.

• Contact the Colorado QuitLine at 1-800-QUIT-NOW (1-800-784-8669) for free coaching and support.
• Talk with your health care provider about the benefits and risks of taking smoking cessation medications while you are pregnant. Health Care Colorado covers two 90-day courses of smoking cessation medication with counseling to help you quit.

Early refills are covered when there is an increase in dosage or if a client is going into or leaving a nursing home. Clients may receive up to a 100 day supply of maintenance medications and up to a 30 day supply of non-maintenance medications. If you run out of medication, contact your doctor and discuss adjusting your prescription to your current needs.

Health First Colorado (Colorado’s Medicaid program) does not pay for vacation supplies.

Through scientific testing, the Food and Drug Administration (FDA) ensures that generic drugs are safe and effective, contain the same active ingredient and work the same way as the brand name. Health First Colorado (Colorado’s Medicaid Program) can pay for a name brand drug if a generic is not available, if your doctor considers the name brand to be medically necessary or if the medication is excluded from the generic mandate (e.g., medications for mental illness, cancer, epilepsy and HIV/AIDS). In cases where your doctor would like you to have the brand name when a generic is available, a prior authorization will need to be completed by your doctor and the prior authorization must be approved by Health First Colorado before you will be allowed to receive the brand name.

Health First Colorado (Colorado’s Medicaid Program) will cover lost, stolen or damaged medications once per lifetime for each member. Pharmacies must call for overrides for lost, stolen, or damaged prescriptions. Please call your pharmacy and they will need to call Magellan (1-800-424-5725) to request the replacement prescriptions. The replacement request and verification must be within 60 days of the last refill of the medication.

Health First Colorado (Colorado’s Medicaid Program) covers smoking cessation products (e.g. Chantix, nicotine patches and nicotine gum) with a prior authorization.

Learn more about how to Quit Smoking.

Beginning July 1, 2023 if your prescription is for a generic or brand name medication you will not have a co-pay.

Learn more about Health First Colorado Co-Pays.

Once a Health First Colorado (Colorado’s Medicaid program) member is entitled to receive Medicare, Medicare Part D will cover most of your prescriptions. Health First Colorado will only pay for a few medications that are excluded by your Part D plan. If you need assistance to find and enroll on a Part D plan, please call 1-888-696-7213 or 303-894-2946.

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Health First Colorado members have the option of getting their prescription medications through the mail instead of going to the pharmacy.

Delivery Fees

• Health First Colorado does not pay for or reimburse pharmacies or members for delivery fees.
• Pharmacies may offer mail delivery, but it is up to each pharmacy whether they provide this service.
• If you choose mail delivery for your prescription medication, you are responsible for paying the delivery fee, if applicable.

How to get your prescription by mail

1. Check with Your pharmacy: Ask your current pharmacy if they provide mail delivery for your prescriptions.

2. If your current pharmacy does not offer mail delivery, and you want to stay local:

• • Search for nearby pharmacies using the Find a Doctor tool.
  • Enter your address in the “Find Providers Near Me” field, or click the “Find Me” button to see your location.
  • Adjust the “Within” tool to set how far you are willing to travel.
  • Select “Pharmacy” from the “Find Providers by Type” dropdown list.
  • Call nearby pharmacies to ask about their delivery options.

3. If no local pharmacies offer mail delivery:

• Search for mail order pharmacies using the Find a Doctor tool.
• Select “Pharmacy” from the dropdown list.
• Zoom out using the “-” button on the map to find other areas or out-of-state pharmacies that might offer mail order services.
• If you choose mail order services, you can get new or refill prescriptions for chronic conditions in a supply of up to 100 days. These are called maintenance medications, which are taken regularly to manage a wide range of ongoing or long-term conditions and illnesses.

Important

Health First Colorado does not keep an official list of pharmacies that offer mail delivery. We recommend that you call pharmacies directly and ask if they can meet your specific medication needs.

Questions?

If you need more information, call the Pharmacy Liaison at 303-866-3588.

Diabetic supplies such as test strips, lancets and syringes are a covered medical benefit and not a pharmacy benefit. Please ask the pharmacy to bill DME-Supplies. Pharmacies can call 1-800-237-0757 if they require additional assistance billing supplies.

Some medications require your doctor to file a prior authorization request before a medication will be covered. Please ask your doctor to contact Health First Colorado (Colorado’s Medicaid program) at 1-800-424-5725 to request a prior authorization for your medication. Once the prior authorization is submitted, it will take up to 24 hours to process.