CurrentDenver-Health-Medical-PlanPolicy N/A

Elevate Medicaid Choice and Elevate CHP+ Formulary Information

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

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

SourceLink

On This Page

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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.

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

1/7

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

Note

OpenPayer