C.R.S. § 10-16-145.5: Step therapy - prior authorization - prohibited - stage four advanced metastatic cancer - non-opioid pain management drug - definitions.

(1) Notwithstanding section 10-16-145, a carrier that provides coverage under a health benefit plan for the treatment of stage four advanced metastatic cancer shall not limit or exclude coverage under the health benefit plan for a drug that is approved by the FDA and that is on the carrier's prescription drug formulary by mandating that a covered person with stage four advanced metastatic cancer undergo step therapy if the use of the approved drug is consistent with:

(a) The FDA-approved indication or the National Comprehensive Cancer Network drugs and biologics compendium indication for the treatment of stage four advanced metastatic cancer; or

(b) Peer-reviewed medical literature.

(2) Notwithstanding section 10-16-145, a carrier that provides prescription drug benefits shall:

(a) Provide coverage for at least one atypical opioid that has been approved by the FDA for the treatment of acute or chronic pain at the lowest tier of the carrier's drug formulary and not require step therapy or prior authorization, as defined in section 10-16-112.5 (7)(d), for that atypical opioid; and

(b) Not require step therapy for the prescription and use of any additional atypical opioid medications that have been approved by the FDA for the treatment of acute or chronic pain.

(2.5) (a) Notwithstanding section 10-16-145, a carrier that provides prescription drug benefits shall require that:

(I) The utilization review requirements, including prior authorization and step therapy, for a non-opioid drug prescribed and approved by the FDA for the treatment or management of chronic or acute pain are no more restrictive than the least restrictive utilization review requirements for opioid drugs prescribed for the treatment or management of chronic or acute pain; and

(II) The cost sharing, copayment, or deductible for a non-opioid drug prescribed for the treatment or management of chronic or acute pain is no greater than the cost sharing, copayment, or deductible for an opioid drug prescribed for the treatment or management of chronic or acute pain.

(b) (I) Except as provided in subsection (2.5)(b)(II) of this section, all individual and small group health benefit plans issued or renewed in this state on or after January 1, 2027, shall ensure there is at least one non-opioid prescription drug available as a clinically appropriate alternative for an opioid prescription drug.

(II) Subsection (2.5)(b)(I) of this section is inoperative and the state shall not assume an obligation for the coverage required pursuant to subsection (2.5)(b)(I) of this section if the division determines that the benefit specified in subsection (2.5)(b)(I) of this section requires state defrayal of the cost of coverage pursuant to a provision of the federal act, including 42 U.S.C. sec. 18031 (d)(3)(B) or a successor provision, and the implementing regulations or the state is otherwise required to defray the cost of coverage required pursuant to subsection (2.5)(b)(I) of this section.

(III) All large employer health benefit plans issued or renewed in this state on and after January 1, 2028, shall ensure there is at least one non-opioid prescription drug available as a clinically appropriate alternative for an opioid prescription drug.

(IV) The coverage required by this subsection (2.5) may be offered through a high deductible plan that would qualify for a health savings account pursuant to 26 U.S.C. sec. 223; except that a carrier may apply deductible amounts for the required coverage if it is not considered by the United States department of the treasury to be preventive or to have an acceptable deductible.

(c) This subsection (2.5) does not apply to a group benefit plan issued pursuant to the "State Employees Group Benefits Act", part 6 of article 50 of title 24.

(3) As used in this section:

(a) "Atypical opioid" means an opioid agonist with a documented safer side-effect profile and less risk of addiction than older opium-based medications.

(b) "Stage four advanced metastatic cancer" means cancer that has spread from the primary or original site of the cancer to nearby tissues, lymph nodes, or other parts of the body.

(c) "Step therapy" has the same meaning as specified in section 10-16-145 (1)(g).