CurrentDenver-Health-Medical-PlanPolicy N/A
Elevate Medicaid Choice and Elevate CHP+ Formulary Information
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Part 1 of the Elevate Medicaid Choice and Elevate CHP+ closed formulary describing formulary purpose, selection process, prior authorization/step-therapy/quantity-limit definitions, member/provider contact information, exclusions, supply/renewal rules, tier structure, and sample medication entries with levels and requirements.
Policy Summary
PayerDenver-Health-Medical-Plan
PolicyElevate Medicaid Choice and Elevate CHP+ Formulary Information
Policy CodePolicy N/A
Change TypeNo material change
Effective Date
Next Review Date
Key ActionSubmit a Prior Authorization Request (PAR) with clinical justification for medications requiring PA/LA/ST using DHMP Pharmacy Department contact methods and include prior therapy history as required.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this update.
closedFormulary Type
0-3Formulary Levels
multipleRestricted drugs (PA/LA/QL/ST)
100+Drugs listed (sample)
fewEntries with age restrictions
Coverage Summary & Exception Process
Formulary Coverage and Exception Process
Only medications listed on the Elevate Medicaid Choice and Elevate CHP+ Formulary are covered under the pharmacy benefit. The Formulary is a closed list managed by the Denver Health Pharmacy & Therapeutics (P&T) Committee. When a medication is not on the Formulary, an exception (Prior Authorization) may be requested and will be reviewed case-by-case.
Only medications listed on the Elevate Medicaid Choice and Elevate CHP+ Formulary are covered by the pharmacy benefit. All medications require a prescription from a provider to be eligible for pharmacy coverage.
Formulary governance and selection: The Denver Health Pharmacy & Therapeutics (P&T) Committee (physicians and pharmacists) regularly reviews medications. Selection considerations include FDA approval, safety, efficacy, comparative studies, approved indications, adverse effects, contraindications/warnings/precautions, pharmacokinetics, patient adherence considerations, clinical outcomes, and pharmacoeconomics.
Exception workflow (Prior Authorization / Step Therapy): If a prescribed medication is not on the Formulary or requires utilization controls, the pharmacy may reject the claim and request a Prior Authorization Request (PAR) or exception. The pharmacy may contact the prescriber to suggest a therapeutic alternative listed on the Formulary. Providers may submit PARs to the DHMP Pharmacy Department by phone, fax, or electronically. Clinical information demonstrating medical necessity must be included on the PAR.
Review process and resources: DHMP reviews PARs and exception requests individually using applicable criteria, Health First Colorado criteria when present, and clinical guidelines (e.g., National Guideline Clearinghouse/AHRQ) as appropriate. Members/providers may request copies of the guidelines or criteria used. Providers must respond to requests for additional information within 72 hours per Colorado regulations. Expedited reviews are available for urgent situations. After review, DHMP will notify member and provider of the decision and provide appeal rights if denied.
Transition supply: New members may be eligible for a transition fill supply for medications not on the Formulary or for prescriptions exceeding Formulary quantity limits to allow time for the provider to prescribe a Formulary alternative or submit a PAR.
PA / LA / QL / ST Definitions
Definitions of authorization and utilization controls used on the Formulary:
Prior Authorization (PA): A requirement that the prescriber obtain approval from DHMP before the drug will be covered. A PA requires submission of clinical rationale and supporting documentation showing medical necessity according to plan criteria.
Limited Access (LA): Products designated as access-limited that may only be dispensed through specific pharmacies (e.g., Denver Health/Hospital Authority pharmacies or designated specialty pharmacies) or have site-of-service restrictions. LA items commonly include many specialty medications.
Quantity Limit (QL): A restriction on the amount or dosing frequency of a medication that will be covered during a specified time period. Prescriptions exceeding QL require a PA with justification.
Step Therapy (ST): A requirement that specified preferred medication(s) on the Formulary be tried and found ineffective, not tolerated, or contraindicated before coverage of a non-preferred agent is approved. Documentation of trials and clinical response is required for ST exceptions.
Additional Coverage Details
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.
Coverage Criteria and Limits (by product examples)
Step Therapy / Initial Therapy Requirements
Continuation Therapy & Refill Rules
Exclusions / Not Covered
Applicable Product & Code Groups
Formulary medication entries sample linesmixedCovered
| acetaminophen oral elixir 160 mg/5 ml | Acetaminophen oral elixir 160 mg/5 ml (children's formulations) |
| acetaminophen oral liquid 160 mg/5 ml | Acetaminophen oral liquid 160 mg/5 ml |
| acetaminophen oral liquid 500 mg/15 ml | Acetaminophen oral liquid 500 mg/15 ml |
| acetaminophen oral solution 160 mg/5 ml | Acetaminophen oral solution 160 mg/5 ml |
| 325 mg/10.15 ml | Acetaminophen concentration 325 mg/10.15 ml formulation |
| 650 mg/20.3 ml | Acetaminophen concentration 650 mg/20.3 ml formulation |
| acetaminophen-codeine oral solution 120 mg-12 mg/5 ml | Acetaminophen-codeine oral solution 120 mg-12 mg/5 ml |
| 300 mg-30 mg/12.5 ml | Acetaminophen-codeine 300 mg-30 mg per 12.5 ml |
| acetaminophen-codeine oral tablet 300-15 mg | Acetaminophen-codeine oral tablet 300-15 mg |
| acetaminophen-codeine oral tablet 300-30 mg | Acetaminophen-codeine oral tablet 300-30 mg |
1–10 of 68
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Excluded categoriesmixedNot Covered
| cosmetic uses | Medications and products for cosmetic purposes (anti-wrinkle, hair removal, hair growth) |
| dietary supplements | Dietary supplements, vitamins and herbal products not on formulary |
| infertility treatments | Medications to assist in achieving pregnancy (infertility treatments) |
| travel vaccines (CDC travel only) | Vaccines recommended only for travel by CDC (not covered) |
| non-FDA-approved prescriptions | Prescriptions not approved by the FDA for the indicated disease (not covered) |
Listed drugs with utilization controls (partial)mixedCovered
| Listed drugs with utilization controls (examples) | See individual formulary criteria; select specialty agents, PA or step therapy may apply (e.g., biologics, migraine monoclonals) |
Listed drugs with QL (quantity limits)mixedCovered
| Items with quantity limits (examples shown) | Select acute and chronic therapies have quantity limits per fill or per time period (see formulary appendix) |
Formulary OTC entries (LA or OTC designated)mixedCovered
| acetaminophen oral elixir 160 mg/5 ml | Children's acetaminophen OTC formulation — covered as OTC/formulary entry where designated |
| acetaminophen oral liquid 160 mg/5 ml | Children's acetaminophen liquid — OTC formulary entry |
| ibuprofen oral suspension 100 mg/5 ml | Children's ibuprofen oral suspension — OTC formulary entry |
Items with quantity limits (examples shown)mixedCovered
| fentanyl transdermal patch 12 mcg/hr - 100 mcg/hr | Quantity limits and fill intervals apply per policy |
| benzodiazepines (selected strengths) | Controlled substances have refill/renewal timing limits (85% rule) and quantity limits |
| acetaminophen oral solution 160 mg/5 ml | Children's acetaminophen — may have OTC dispensing limits |
Provider Actions & Operational Requirements
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Formulary Background & Scope
Revision History
Policy Summary
PayerDenver-Health-Medical-Plan
PolicyElevate Medicaid Choice and Elevate CHP+ Formulary Information
Policy CodePolicy N/A
Change TypeNo material change
Effective Date
Next Review Date
Key ActionSubmit a Prior Authorization Request (PAR) with clinical justification for medications requiring PA/LA/ST using DHMP Pharmacy Department contact methods and include prior therapy history as required.
SourceLink
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