Pharmacy Resources
COVID-19
Prior Authorization Policies
Health First Colorado (Colorado's Medicaid Program) provides pharmaceutical benefits to Health First Colorado members. Some of these products require prior authorization approval. All of the products subject to prior authorization are listed on the Preferred Drug List or Appendix P, both of which are listed below.
A provider can submit a request either by phone or by fax to Health First Colorado’s Prior Authorization Helpdesk. The Helpdesk phone number is 1-800-424-5725 and the fax number is 1-800-424-5881. It is open 24 hours a day, seven days a week.
Pharmacy Prior Authorization webinar (a review of Pharmacy Prior Authorization and Hepatitis C Prior Authorization request information).
Preferred Drug List (PDL)
The PDL is developed based on safety, effectiveness, and clinical outcomes from classes of medications where there are multiple drug alternatives available and supplemental rebates from drug companies, allowing Colorado the ability to provide medications at the lowest possible costs.
| Current PDL |
|---|
| January 1, 2021 |
| October 1, 2020 |
| July 1, 2020 |
| April 1, 2020 |
| January 1, 2020 |
| October 1, 2019 |
| July 1, 2019 |
| April 1, 2019 |
| January 1, 2019 |
Please visit the Pharmacy and Therapeutics (P&T) Committee page for more information.
Manufacturer Information
Preferred Drug List Drug Class Announcements are sent via email at least 45 days prior to each P&T Committee Meeting review. Supplemental rebate offers should be submitted to Provider Synergies / Magellan Rx Health.
For manufacturer presentations, please see P&T Policies and Procedures.
Appendix P - Pharmacy Benefit Prior Authorization Procedures and Criteria
| Appendix P |
|---|
| January 1, 2021 |
| October 1, 2020 |
| July 1, 2020 |
| April 1, 2020 |
| January 1, 2020 |
| October 1, 2019 |
| July 1, 2019 |
| April 1, 2019 |
| January 1, 2019 |
Hepatitis C Prior Authorization
- Hepatitis C Prior Authorization Request Form - Effective January 1, 2021 (Revised January 2021)
- Hepatitis C Treatment Outcomes
Global Prior Authorization
The Global Prior Authorization policy was developed to protect the health of Health First Colorado's most vulnerable members. Members who qualify will be exempt for one year from prior authorization requirements for non-preferred drugs. They will also be exempt from prior authorization requirements for non-PDL drugs currently requiring prior authorization. Clients who do not qualify for a Global Prior Authorization may still be eligible for prior authorizations for individual drugs.
Appeal Rights
Learn about Appeal Rights for Health First Colorado members.
Mail Order
Learn about Mail Order Prescriptions for Health First Colorado members.
Miscellaneous Forms and Other Information
- Drugs Covered by Medicaid for Medicare-Medicaid (Dual Eligible) Members
- Pharmacy Prior Authorization Form
- Pharmacy Claim Form
- Other Coverage Code Quicksheet
- Pharmacy Refund Form
- Pain Management Resources and Opioid Use
- Billing Health First Colorado Members for Services
Pharmacy Billing Manual
The Pharmacy Billing Manual explains the billing policies, provider responsibilities, and program benefits for Health First Colorado's pharmacy office. Providers should also consult the Code of Colorado Regulations (10 C.C.R. 2505-10 Volume 8) for further guidance regarding benefits and billing requirements.
Pharmacist Immunization and OTC Prescriptive Authority List
- This document contains the drugs that pharmacists may prescribe to members once enrolled with Health First Colorado: OTC Prescriptive Authority List
- For more information specific to pharmacist enrollment, please see the Pharmacist Enrollment: Over-the-Counter and Immunizations page.
- For more information on Immunizations, please see the Immunizations Billing Manual.
340B Policy and Procedures Manual
This document contains the Health First Colorado policies and procedures for Managed Care Organization and Fee-for-Service providers who participate in the 340B Drug Pricing Program. This guidance applies to prescription drugs dispensed in an outpatient setting (i.e., pharmacy) and drugs administered in a physician’s office or clinic. This guidance does not apply to prescription drugs provided in an inpatient or outpatient hospital setting.
340B Policy and Procedures Manual
Physician Administered Drugs
Learn more about Physician Administered Drugs for Health First Colorado members.
Prescriber Tool Project
The Department is implementing the Prescriber Tool, a multifunctional platform which will be accessible to prescribers through most electronic health record (EHR) systems. The opioid risk module will be implemented first and is anticipated to be operational in January 2021. For more information, please visit the Prescriber Tool Project page.
Rx Review Program
The Rx Review Program has been updated. The Pharmacy Office took a comprehensive approach to make the program more robust. The Department decided the most effective way to assist members in a more cohesive and timely fashion was to transition the Rx Review Program to the CU School of Pharmacy. All Rx Review consulting needs for our members are now under the direction of the professors and pharmacy interns at the CU School of Pharmacy.