Medicaid Pharmacy Benefit Frequently Asked Questions (FAQs)

How much should I be charged for my prescription medications?

If your prescription is for a generic medication, your co-payment will only be $1.00. If your prescription is for a brand name medication, your co-payment will only be $3.00. Clients 18 years of age and younger, clients in a nursing home and clients in a maternity cycle or 60 days postpartum do not have a co-payment.

Can I get my medication early?

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.

Can I get my medications early if I am going on vacation?

Colorado Medicaid does not pay for vacation supplies.

My pharmacy told me my diabetic supplies are not covered. Is that true?

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.

My pharmacy told me my medication is denied because a prior authorization was needed. What should I do?

Some medications require your doctor to file a prior authorization request before a medication will be covered. Please ask your doctor to contact Colorado Medicaid 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.

Can I get the name brand medication when a generic is available?

Through scientific testing, the FDA ensures that generic drugs are safe and effective, contain the same active ingredient and work the same way as the brand name. Colorado Medicaid 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 Colorado Medicaid before you will be allowed to receive the brand name.

Are over-the-counter (OTC) medications covered?

Insulin and aspirin are covered without a prior authorization. All other OTCs require a prior authorization before approval unless an OTC is a preferred product on the PDL.

Can I request an early refill if my medication was lost or stolen?

Colorado Medicaid will cover lost, stolen or damaged medications once per lifetime for each client. Stolen prescriptions will require a copy of the police report to be submitted/faxed to the state before approval will be granted. For assistance, please contact the Department at 303-866-3588 or 800-221-3943.

I am covered by Medicare and Medicaid. Why is Medicaid not paying for my prescriptions?

Once a Colorado Medicaid client is entitled to receive Medicare, Medicare Part D will cover most of your prescriptions. Colorado Medicaid 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.

Does Medicaid cover smoking cessation products (e.g. Chantix, nicotine patches and nicotine gum)?

Colorado Medicaid covers smoking cessation products with a prior authorization. Learn more about how to Quit Smoking.