DRUGS COVERED BY MEDICAID FOR MEDICARE-MEDICAID (DUAL ELIGIBLE) MEMBERS

Cough and Cold Products Over-the-Counter (OTC) Products Prescriptions Vitamin and Mineral Products

Other Products

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 Magellan

Helpdesk at 800-424-

5725.

Note:

Prescription (Rx) cough and cold

products are not a covered

benefit for dual eligible members

21 years and older.

Prescription (RX) required

products:

PA required for members who

are under 21 years old and

require the cough and cold

product for a diagnosis of a non-

chronic condition, such as acute

cold.

Over the Counter products:

Covered products may include

children’s liquid and chewable

Tylenol and ibuprofen, cough

suppressants (Dextromethorphan

for ages 4-11 years), and

decongestants. Products may

require a PA in accordance with

the current Preferred Drug List

(PDL) and Appendix P criteria,

example: non-preferred anti-

histamines.

Note:

Some OTC products are covered by Health First

Colorado, of the OTC products that are covered, the coverage policy and criteria may be found on the

Preferred Drug List (PDL) and/or Appendix P.

Covered medications may include: anti- allergy

(Claritin/loratadine), acid reflux

(Prilosec/omeprazole), nasal allergy products, and allergy eye drops (Zaditor/ ketotifen).

Non-preferred agents may require a PA, examples:

vitamin B6 or doxylamine for nausea in pregnancy

(morning sickness).

Aspirin, Emergency Contraception (Plan B),

Ibuprofen (6 months – 11 years), generic Miralax,

OTC smoking cessation agents (Nicotine

patch/gum/lozenge), and Tylenol (2-11 years) are

covered without a PA.

Prescription vitamin and

mineral products may be

covered consistent with

the Appendix P and PDL

criteria. PA may be

required, example:

vitamin K, vitamin B12,

folic acid.

Note:

Prenatal vitamins and

Vitamin D analogues

(Doxercalciferol, Calcitriol

and Paricalcitol) are not a

covered benefit for dual

eligible members because

these products are

covered by Medicare.

Heparin and Saline

Flush

Updated: March 2019

The Appendix P and Preferred Drug List (PDL) criteria can be found here:

• Pharmacy Resources

Additional References:

• Medicare Prescription Drug Benefit Manual

• Payment for Covered Outpatient Drugs

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