Refill / Renewal rules: Non-controlled prescriptions are eligible for refill authorization when 75% of the existing supply has been used. Controlled prescriptions are eligible when 85% of the existing supply has been used. These percentages are calculated from the directions on the original prescription. If the indication or directions change, the prescriber should provide an updated prescription.
90-day supply and mail service: Members may receive a 90-day supply for most maintenance medications with a $0 copay when the prescription is written for a 90-day supply. Pharmacies may not dispense a 90-day supply without the prescriber's authorization. Denver Health Pharmacy by Mail is available for Denver Health prescribers and can deliver 90-day supplies for certain medications. Specialty medications are typically limited to 30-day supplies and may be restricted to designated specialty or DHHA pharmacies.
Excluded medications: The following categories are excluded from pharmacy coverage under the benefit: cosmetic uses (anti-wrinkle, hair removal, hair growth), dietary supplements/vitamins not on the Formulary, infertility treatments for assisted reproduction, skin pigmentation agents, performance/enhancement and sexual dysfunction agents (e.g., Viagra, Cialis, Levitra), weight loss medications, investigational or experimental treatments, prescription drugs not FDA-approved for any indication, travel-only CDC-recommended vaccines for travel outside the U.S. (covered travel vaccines are listed on the Formulary), and drugs from manufacturers not participating in the Colorado Medicaid Drug Rebate Program.
Formulary entries and per-product requirements/limits: The Formulary includes coverage-level designations and per-product utilization controls (e.g., PA, LA, QL, ST). Products listed with PA require prior authorization with clinical justification. Products listed as LA may require dispensing at specified pharmacies or specialty channels. Quantity limits and step therapy rules are documented on the Formulary entry for each product. Providers and pharmacies should consult the Formulary entry for specific coverage criteria, required documentation, trial medications for ST, and numeric QL thresholds.
General formulary entry criteria: The P&T Committee evaluates clinical evidence, comparative effectiveness, safety profile, FDA-approved indications, cost-effectiveness, and therapeutic alternatives when deciding Formulary placement and coverage level. Brand drugs may be placed on the Formulary when clinically preferred or when no adequate generic alternative exists.
Specific step therapy requirements: For medications subject to ST, the Formulary specifies required first-line agents, acceptable trial durations, therapeutic response criteria, and allowable exceptions (e.g., intolerance or contraindication). Providers submitting a PA for a step therapy exception must document prior trials and outcomes or a clinical reason that first-line agents are inappropriate.
Products with PA (LA) or quantity limits: A subset of specialty and high-cost products are managed with LA designations or PA requirements and often have QLs. These include many specialty injectables, infused biologics, and some oral specialty agents. Specific product lists and restrictions are maintained on the Formulary web pages and within the plan's PA criteria.
Coverage-level criteria and restrictions (by product): Each Formulary product entry includes the coverage level (preferred/non-preferred/excluded), applicable utilization controls (PA, LA, QL, ST), clinical criteria for approval, required documentation, and any site-of-service or pharmacy channel restrictions.
Formulary item-level requirements: For any given Formulary line, providers must follow the documented requirements (e.g., specific diagnoses, prior trial durations, monitoring requirements, lab results, dosing limits). Failure to submit required documentation may result in denial and will trigger member/provider notification with appeal rights.