(c) For nonurgent prior authorization requests related to a covered person's HIV prescription drug coverage, the prior authorization request is deemed granted if a carrier or pharmacy benefit management firm fails to:
(I) Utilize the prior authorization process developed pursuant to subsection
(3) of this section;
(II) For prior authorization requests submitted electronically:
(A) [Editor's note: For the applicability of this subsection (2)(c)(II)(A) on or after January 1, 2026, see the editor's note following this section.] Notify the prescribing provider, within one business day after receipt of the request, that the request is approved, denied, or incomplete and, if incomplete, indicate the specific additional information, consistent with criteria posted pursuant to subsection
(3.5)(a) of this section, that is required to process the request; or
(B) Notify the prescribing provider within one business day after receiving the additional information required by the carrier or pharmacy benefit management firm pursuant to subsection (2)(a)(II)(A) of this section that the request is approved or denied; and
(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.
(c.5) This subsection (2)(c.5) and subsection (2)(c) of this section are repealed, effective July 1, 2027.
(3) (a) [Editor's note: For the applicability of this introductory portion to subsection (3)(a) on or after January 1, 2026, see the editor's note following this section.] The commissioner shall develop, by rule, a uniform prior authorization process that:
(I) [Editor's note: For the applicability of this subsection (3)(a)(I) on or after January 1, 2026, see the editor's note following this section.] 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(II) Repealed.
(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) [Editor's note: For the applicability of this subsection (3)(a)(VI) on or after January 1, 2026, see the editor's note following this section.] 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.
(b) [Editor's note: For the applicability of this introductory portion to subsection (3)(b) on or after January 1, 2026, see the editor's note following this section.] In developing the uniform prior authorization process, the commissioner shall take into consideration the following:
(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.
(c) In addition to the prior authorization process, the commissioner shall develop, by rule, a standardized prior authorization form, not to exceed two pages in length, for use in submitting electronic and nonelectronic prior authorization requests. In developing the form, the commissioner shall take into consideration existing forms, including existing prior authorization forms established by the federal centers for medicare and medicaid services or the department of health care policy and financing.
(3.3) [Editor's note: For the applicability of this subsection (3.3) on or after January 1, 2026, see the editor's note following this section.] Starting January 1, 2027, if a provider submits a prior authorization request to a carrier or PBM through a secure electronic transmission system the carrier or PBM uses that complies with the most recent version of the National Council for Prescription Drug Programs SCRIPT standard, or its successor standard, and 21 CFR 1311, the carrier or PBM shall accept and respond to the request through the secure electronic transmission system.
(3.5) [Editor's note: For the applicability of this subsection (3.5) on or after January 1, 2026, see the editor's note following this section.]
(a) On and after January 1, 2026, a carrier shall post on the carrier's public-facing website, in a readily accessible, standardized, searchable format, prior authorization requirements as applicable to the prescription drug formulary for each health benefit plan the carrier offers, including the following information:
(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:
(A) Any tiering structure, including copayment and coinsurance requirements;
(B) Prior authorization, step therapy, and other utilization management controls;
(C) Quantity limits; and
(D) Whether access is dependent upon the location where a prescription drug is obtained or administered; and
(VIII) The appeal process for a denial of coverage or adverse determination for an item or service for a prescription drug.
(b) The commissioner shall adopt rules as necessary to implement this subsection (3.5).
(4) Repealed.
(5) [Editor's note: For the applicability of this subsection (5) on or after January 1, 2026, see the editor's note following this section.]
(a) Notwithstanding any other provision of law, and except as provided in subsections (5)(b) and (5.5) of this section, every prescribing provider shall use the prior authorization process developed pursuant to subsection (3) of this section to request prior authorization for coverage of drug benefits, and every carrier and pharmacy benefit management firm shall use that process for prior authorization for drug benefits.
(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:
(A) There is evidence that the authorization was obtained from the carrier or PBM based on fraud or misrepresentation;
(B) Final action by the FDA or other regulatory agencies, or the manufacturer, removes the chronic maintenance drug from the market, limits its use in a manner that affects the authorization, or communicates a patient safety issue that would affect the authorization alone or in combination with other authorizations;
(C) A generic equivalent or drug that is biosimilar, as defined in 42 U.S.C. sec. 262 (i)(2), to the prescribed chronic maintenance drug is added to the carrier's or PBM's drug formulary; or
(D) The wholesale acquisition cost of the chronic maintenance drug exceeds a dollar amount as established by the commissioner by rule, which amount must be no less than thirty thousand dollars for a twelve-month supply or for a course of treatment that is less than twelve months in duration.
(III) Nothing in this subsection (5)(b) requires a carrier or PBM to pay for a benefit:
(A) That is not a covered benefit under the health benefit plan; or
(B) If the patient is no longer a covered person under the health benefit plan on the date the chronic maintenance drug was prescribed, dispensed, administered, or delivered.
(IV) As used in this subsection (5)(b), chronic maintenance drug has the meaning set forth in section 12-280-103 (9.5).
(5.5) [Editor's note: For the applicability of this subsection (5.5) on or after January 1, 2026, see the editor's note following this section.]
(a) No later than January 1, 2026, a carrier or PBM shall adopt a program, developed in consultation with providers participating with the carrier, to eliminate or substantially modify prior authorization requirements in a manner that removes the administrative burden for qualified providers, as defined under the program, and their patients for certain prescription drugs and related drug benefits based on any of the following:
(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.
(b) A program developed pursuant to subsection (5.5)(a) of this section:
(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.
(c) At least annually, a carrier or PBM shall:
(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.
