Pharmacy Resources

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Pharmaceutical Benefit Help Guide

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 fax by contacting the 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. A provider may also submit electronic prior authorization requests via their Electronic Health Record (EHR) system or through the CoverMyMeds provider portal.

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.

Please visit the Pharmacy and Therapeutics (P and 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 and T Committee Meeting review. Supplemental rebate offers should be submitted to Provider Synergies / Prime Therapeutics.

For manufacturer presentations, please see P and T Policies and Procedures.

Appendix P - Pharmacy Benefit Prior Authorization Procedures and Criteria

FAQs - P and T Committee and DUR Board Decision Making Process

• After the Pharmacy and Therapeutics (P and T) Committee meeting: Final preferred product decisions for drug classes reviewed during the meeting will be publicly available to view on the P and T Committee website prior to the subsequent Drug Utilization Review (DUR) Board meeting. The preferred product changes will be additionally published in the provider bulletin.
• After the DUR Board meeting: Final prior authorization (PA) criteria for drugs/drug classes reviewed during the meeting will be publicly available to view on the first day of the month following the meeting by referencing the posted preferred drug list (PDL) and Appendix P documents on the Pharmacy Resources webpage. For example, for drugs/drug classes reviewed at January P and T/February DUR, the final PA criteria will be posted and available to view on March 1st (with an effective date of 4/1/xx).
• The P and T Committee and DUR Board meeting minutes are available publicly on their respective webpages, after they are approved by the respective boards. Approval of the minutes occurs at the next quarters' P and T/DUR meeting.
• Additionally, for information about physician/healthcare provider administered drugs (PADs), please see the PAD Resources webpage.

Brand Favored Product List - Pharmacy Benefit Brand Favored Product Coverage

Pharmacy Prior Authorization Request

• Pharmacy Prior Authorization Form

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. Members who do not qualify for a Global Prior Authorization may still be eligible for prior authorizations for individual drugs.

• Global Prior Authorization Criteria
• Global Prior Authorization Form

Serious or Complex Medical Condition Step Therapy Exception Request Form

A provider may request a step therapy exception for the treatment of a serious or complex medical condition pursuant to section 25.5-4-428, C.R.S. Serious or complex medical condition means the following medical conditions: serious mental illness, cancer, epilepsy, multiple sclerosis, or human immunodeficiency virus (HIV)/ acquired immune deficiency syndrome (AIDS), or a condition requiring medical treatment to avoid death, hospitalization, or a worsening or advancing of disease progression resulting in significant harm or disability. Members who qualify may be granted an exemption to step therapy requirements for the requested drug for one year.

Serious or Complex Medical Condition Step Therapy Exception Request Form 

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 Claim Form
• Other Coverage Code Quicksheet
• Pharmacy Refund Form
• Pain Management Resources and Opioid Use
• Billing Health First Colorado Members for Services
• Synagis Pharmacy Benefit Prior Authorization Request Form
• Covered Prescribed Drugs

MCO and CHP+ Information

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 Services Information

• This document contains the drugs that pharmacists may prescribe to members once enrolled with Health First Colorado: OTC Prescriptive Authority List
• For more information regarding pharmacist services, please see the Pharmacist Services Billing Manual.
• 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 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 implemented the Prescriber Tool, a multifunctional platform which is accessible to prescribers through most electronic health record (EHR) systems. For more information, please visit the Prescriber Tool Project page.

Resource for Medicaid Enrolled Providers Managing Chronic Pain Treatment

In partnership with the University of Colorado School of Pharmacy and Board-certified pain specialists, Health First Colorado offers additional education, resources and ongoing clinical support to Medicaid enrolled providers managing the needs of HCBS Members who experience chronic pain. For more information or to submit a referral, please contact Judy Mooney, Chronic Pain Referral Coordinator at judy.mooney@state.co.us or call 303-866-5547.

Value Based Contracting

The pharmacy team at Health First Colorado (the Department) is seeking opportunities to partner with pharmaceutical manufacturers through Value Based Contracting arrangements. The Department has a CMS approved Value Based Contracting template and we are encouraging manufacturers that are interested in collaborating in a mutually beneficial manner to email hcpf_Colorado.SMAC@state.co.us. We request the following information on the email:

• Manufacturer name / Representative name
• Drug(s) for Value Based Contracting
• Population involved
• Intervention
• Baseline
• Outcome
• Time horizon

Once the Department receives your request we will be in touch to set-up an appointment by telephone. Thank you for your commitment to health outcomes and value for Coloradans.