Do you know what medications are covered by your plan? Learn more about your formulary, also called a list of covered drugs, and what to do when you go to a pharmacy.
Talk to your primary care provider or RMHP if you have any questions about what medications are covered. You can also learn about the Health First Colorado (Colorado's Medicaid Program) pharmacy benefit, including those covered medications, too.
If you are an RMHP Prime Member, you can refer to the RMHP Prime/CHP+ formulary.
Getting Prescriptions at Pharmacies
If you are part of the RMHP regional organization, you will need to provide the pharmacist with your date of birth and either your Social Security number or Health First Colorado ID number, along with your prescription or refill. You do not need a Member ID card to get your medicine. If you need help finding a pharmacy, contact RMHP Customer Service.
If you're also enrolled in RMHP Prime, you should show your RMHP Member ID card when filling prescriptions. RMHP will mail you this card once you're enrolled with RMHP Prime.
Learn More About the RMHP Prime/CHP+ Formulary
A formulary is a list of covered drugs selected by RMHP for their safety, cost, and effectiveness. Drugs are listed by categories or class. They are placed into cost sharing tiers. It includes both brand and generic prescription medications approved by the U.S. Food and Drug Administration (FDA).
When choosing a medication, you and your doctor should consult the formulary. This drug list will help you and your doctor choose the most cost-effective prescription drugs for your condition. This list also tells you if a medication is generic or brand, and if special rules apply. If your medication is not listed in this document, call RMHP Customer Service.
RMHP continually reviews the RMHP Prime/CHP+ Formulary to stay up-to-date with current drug therapies. If we add or remove a drug, or add prior authorization requirements or quantity limits, we will notify Members taking the drug of the change. When you need to consult your drug list, we encourage you to review the list on our formulary webpage or call RMHP Customer Service to see if a newer version is available.
Cost sharing tiers are the different cost levels you pay for a medication. Each tier is assigned a dollar amount. This is the copay — how much you will pay when you fill a prescription. There may be drugs in more than one cost sharing tier used to treat your condition. Ask your doctor about the most cost-effective drug for your condition.
If your drug is shown as “not covered” in this list, or is not listed at all, contact RMHP Customer Service and ask if your drug is covered. If Customer Service confirms that your drug is not covered, you can ask us to make an exception to our coverage rules, restrictions, or limits. You can ask Customer Service to request a Formulary Exception Review or complete a Formulary Exception Request form found under Learning Center and Commonly Used Forms on this website.
There are two types of exceptions you can ask us to make:
- You can ask us to cover your drug even if it is not on the formulary.
- You can ask us to waive coverage restriction or limits on your drug.
For example, RMHP limits the quantity of certain drugs we will cover. If your drug has a quantity limit, you can ask to waive the limit and cover more. Generally, RMHP will only approve your request for an exception if the alternative drugs included on the formulary would not be as effective in treating your condition and/or would cause you to have a negative reaction.
An OTC medication, or drug you can buy without a prescription, may be the right treatment for some conditions. Talk to your doctor about available OTC options. Even though these medications may not be covered under your pharmacy benefit, they may cost less than your out-of-pocket expense for prescription medications.
Generic medications contain the same active ingredients, which are ingredients that make the medication work, as brand name medications - but they often cost less. Once the patent of a brand-name medication ends, the FDA can approve a generic version with the same active ingredients. Sometimes the same company that makes a brand-name medication also makes the generic version.
The RMHP Prime drug list shows brand-name drugs in bold type (for example, Clobex) and generic drugs in plain type (for example, clobetasol).
The next time your doctor gives you a prescription for a brand-name medication, ask if a generic alternative or lower-cost option is available and if it might be right for you. Generic medications are usually your lowest-cost option. You can access the OptumRx portal to find specific pricing information. OptumRx manages the prescription benefits for RMHP.
If your doctor gives you a prescription for a brand name drug that has a generic version, the pharmacy will substitute the generic, unless you or your doctor requests the brand-name. You may pay more for a brand name drug if a generic is available, or the brand name version may not be covered. Your doctor will need to ask for an exception to our coverage rules in order for us to consider covering a brand name drug when a generic is available.
Specialty medications treat rare or complex conditions and are high-cost medications. These drugs require special handling, approval, administration or monitoring. Some specialty drugs are not available from retail pharmacies and must be obtained from a specialty pharmacy. BriovaRx®, the OptumRx specialty pharmacy, can provide most specialty medications for RMHP Prime Members, along with helpful programs and services.