Drugs Covered by Medicaid for Medicare-Medicaid (Dual Eligible) Members

Covered Drug
Information

Note: Health First Colorado’s (Colorado’s Medicaid program) pharmacy benefit does not cover medications which are covered by Medicare.

If a drug requires a Prior Authorization (PA), please contact the Prime Therapeutics Helpdesk at 800-424-5725.

Only certain designated OTC products are covered by the Health First Colorado pharmacy benefit, and these designated OTC products may be covered by Health First Colorado for members with dual Medicare eligibility. Coverage information for the OTC products that are covered by Health First Colorado can be found on the Preferred Drug List (PDL) and Appendix P.

Covered OTC products in the following therapeutic categories are listed on the Preferred Drug List (PDL):
antihistamines, antihistamine/decongestant combinations, intranasal corticosteroids, ophthalmic allergy drops, proton pump inhibitors, topical NSAIDs (such as diclofenac gel).

For covered OTC products that are not listed on the PDL, coverage information can be found on the Appendix P in the “OTC Products” section. These products include:
aspirin, bisacodyl, children’s dextromethorphan suspension, children’s liquid and chewable acetaminophen, children’s liquid and chewable ibuprofen, cranberry tablets, docusate, ferrous gluconate, ferrous sulfate, fluoride, guaifenesin, l-methylfolate, nicotine replacement products, naloxone, oral contraceptives, emergency contraceptives, polyethylene glycol powder laxative, vitamin D infant drops.

Note: OTC insulin products are covered by Medicare and should be billed to Medicare for members with dual Medicare eligibility.

For members with dual Medicare eligibility, prescription (Rx required) cough and cold medications prescribed for chronic conditions should be billed to Medicare.

Prescription (Rx required) cough and cold medications prescribed for acute conditions are covered by Health First Colorado for members with dual Medicare eligibility with completion of prior authorization verifying treatment of an acute condition.

Prescription (Rx required) prenatal vitamins, niacin products, and certain vitamin D analogues (such as doxercalciferol, calcitriol and paricalcitol) are covered by Medicare and should be billed to Medicare for members with dual Medicare eligibility.

Prescription (Rx required) vitamin and mineral products that are excluded from coverage by Medicare (such as cyanocobalamin, ergocalciferol, folic acid, and vitamin K) are covered by Health First Colorado consistent with Appendix P and PDL coverage criteria. PA may be required.