Step therapy - prior authorization - prohibited - stage four advanced metastatic cancer - opioid prescription - definitions

10-16-145.5. Step therapy - prior authorization - prohibited - stage four advanced metastatic cancer - opioid prescription - 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. (3) As used in this section: (a) A typical 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). Source: L. 2018: Entire section added, (HB 18-1148), ch. 109, p. 799, � 2, effective January 1, 2019. L. 2021: Entire section amended, (HB 21-1276), ch. 364, p. 2396, � 3, effective January 1, 2023. L. 2022: Entire section amended, (HB 22-1370), ch. 184, p. 1233, �� 4, 5, effective August 10. Cross references: For the legislative declaration in HB 21-1276, see section 1 of chapter 364, Session Laws of Colorado 2021.