Colorado Revised Statutes Title 10. Insurance § 10-16-124.5. Prior authorization form--drug benefits--program--rules of commissioner--definitions--repeal

(I) Utilize the prior authorization process developed pursuant to subsection (3) of this section;

(II) For prior authorization requests submitted electronically:

(III) For nonurgent prior authorization requests submitted orally or by facsimile or electronic mail, notify the prescribing provider, within three business days after receipt of the request, that the request is approved or denied; and

(IV) For urgent prior authorization requests submitted orally or by facsimile or electronic mail, notify the prescribing provider, within one day after receipt of the request, that the request is approved or denied.

(I) Utilize the prior authorization process developed pursuant to subsection (3) of this section;

(II) For prior authorization requests submitted electronically:

(III) For nonurgent and urgent prior authorization requests submitted orally, by facsimile, or by electronic mail, notify the prescribing provider within one day after receipt of the request that the request is approved or denied.

(I) Is made available electronically by the carrier or pharmacy benefit management firm, does not require the prescribing provider to submit a prior authorization request electronically, and satisfies the requirements of subsection (3.3) of this section;

(II) Repealed by Laws 2024, Ch. 333 (H.B. 24-1149), § 3, eff. August 7, 2024.

(III) Ensures that carriers and pharmacy benefit management firms use evidence-based guidelines, when possible, when making prior authorization determinations;

(IV) Permits, but does not require, a prescribing provider to submit a request for a prior authorization for drug benefits electronically to the carrier or pharmacy benefit management firm;

(V) Requires carriers and pharmacy benefit management firms, when notifying the prescribing provider of its decision to approve a prior authorization request, to include in the notice a unique prior authorization number attributable to the particular request, specification of the particular drug benefit approved, the next date for review of the approved drug benefit, and a link to the current criteria that the prescribing provider will need to submit for reapproval of the prior authorization; and

(VI) Requires carriers and pharmacy benefit management firms, when notifying a prescribing provider of its decision to deny a prior authorization request, to include the information required by section 10-16-112.5(3)(c)(II) and a notice that the covered person has a right to appeal the adverse determination pursuant to sections 10-16-113 and 10-16-113.5.

(I) National standards pertaining to electronic prior authorization, including, but not limited to, standards referenced in federal law;

(II) Whether the prior authorization process should require carriers and pharmacy benefit management firms, when reviewing a prior authorization request, to use clearly accessible, consistently applied, and written clinical criteria based on medical necessity or the appropriateness of the drug benefit for the covered person;

(III) Whether the prior authorization process should require carriers to take into account, in determining criteria for prior authorizations, the Colorado part B medicare contractor local coverage determinations, the federal centers for medicare and medicaid services national coverage determinations, and specialty society guidelines, such as those of the American Society of Clinical Oncology; and

(IV) Whether carriers and pharmacy benefit management firms could use a rules engine with criteria-driven questions that lead to an immediate determination of a prior authorization request or request for submittal of specific additional information needed to make the determination.

(I) The carrier's prior authorization requirements and restrictions, including a list of drugs that require prior authorization;

(II) Written clinical criteria that are easily understandable to the prescribing provider and that include the clinical criteria for reauthorization of a previously approved drug after the prior authorization period has expired;

(III) The standard form for submitting prior authorization requests;

(IV) The health benefit plan to which the formulary applies;

(V) Each prescription drug that is covered under the health benefit plan, including both generic and brand-name versions of a prescription drug;

(VI) Any prescription drugs on the formulary that are preferred over other prescription drugs or any alternative prescription drugs that do not require prior authorization;

(VII) Any exclusions from or restrictions on coverage, including:

(VIII) The appeal process for a denial of coverage or adverse determination for an item or service for a prescription drug.

(b)(I) A carrier or PBM that provides drug benefits under a health benefit plan shall not impose prior authorization requirements under the health benefit plan more than once every three years for a drug that is approved by the FDA and that is a chronic maintenance drug if the carrier or PBM has previously approved a prior authorization for the covered person for use of the chronic maintenance drug.

(II) This subsection (5)(b) does not apply if:

(III) Nothing in this subsection (5)(b) requires a carrier or PBM to pay for a benefit:

(IV) As used in this subsection (5)(b), “chronic maintenance drug” has the meaning set forth in section 12-280-103(9.5).

(I) The performance of providers with respect to adherence to nationally recognized, evidence-based medical guidelines, appropriateness, efficiency, and other quality criteria; and

(II) Provider specialty, experience, or other objective factors; except that eligibility for the program must not be limited by provider specialty.

(I) Must not require qualified providers to request participation in the program; and

(II) May include limiting the use of prior authorization to providers whose prescribing or ordering patterns differ significantly from the patterns of their peers after adjusting for patient mix and other relevant factors and in order to present those providers with opportunities for improvement in adherence to the carrier's or organization's prior authorization requirements.

(I) Reexamine a provider's prescribing or ordering patterns;

(II) Reevaluate the provider's status for exemption from prior authorization requirements or for inclusion in the program developed pursuant to subsection (5.5)(a) of this section; and

(III) Notify the provider of the provider's status for exemption or inclusion in the program.

(I) An expedited, informal resolution of a carrier's or PBM's failure or refusal to include the provider in the program; and

(II) If the matter is not resolved through informal resolution, binding arbitration as specified in subsection (5.5)(e) of this section.

(I) The provider and carrier or PBM shall jointly select an arbitrator from the list of arbitrators approved pursuant to section 10-16-704(15)(b). Neither the provider nor the carrier or PBM is required to notify the division of the arbitration or of the selected arbitrator.

(II) The selected arbitrator shall determine the provider's eligibility to participate in the carrier's or PBM's program based on the program criteria developed pursuant to subsection (5.5)(a) of this section;

(III) Within thirty days after the date the arbitrator accepts the matter, the provider and the carrier or PBM shall submit to the arbitrator written materials in support of their respective positions;

(IV) The arbitrator may render a decision based on the written materials submitted pursuant to subsection (5.5)(e)(III) of this section or may schedule a hearing, lasting not longer than one day, for the provider and carrier or PBM to present evidence;

(V) Within thirty days after the date the arbitrator receives the written materials or, if a hearing is conducted, the date of the hearing, the arbitrator shall issue a written decision stating whether the provider is eligible for the program; and

(VI) If the arbitrator overturns the carrier's or PBM's failure or refusal to include the provider in the program, the carrier or PBM shall pay the arbitrator's fees and costs, and if the arbitrator affirms the carrier's or PBM's failure or refusal to include the provider in the program, the provider shall pay the arbitrator's fees and costs.

(I) Authorized by law to prescribe any drug or device to treat a medical condition of a covered person; and

(II) Acting within the scope of that authority.

(I) Seriously jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function; or

(II) Subject the covered person to severe pain that cannot be adequately managed without the drug benefit that is the subject of the prior authorization request.