Coverage for nonpharmacological alternatives to opioids and atypical opioid access
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State law specifying required health plan coverage and prescribing rules in Colorado, affecting health benefit plans, prescribers, and insurers operating in Colorado. It mandates coverage of certain nonpharmacological therapies, formulary placement and access rules for atypical opioids, PDMP queries, and prescribing limits for opioids and benzodiazepines.
No material clinical or coverage changes in this revision.
Coverage Criteria
Nonpharmacological Alternative Coverage
Covered when the carrier provides health benefit plan coverage in Colorado:
Cost-sharing capped at primary care nonpreventive visit level.
Prior authorization defined in separate statute (section 10-16-112.5).
Atypical Opioid Coverage
Prescription drug coverage requirements:
Opioid and Benzodiazepine Prescribing Rules
Prescribing limits and exceptions:
Exceptions include clinical judgment and listed care situations; see statute for prescriber types allowed in hospice exception.
Attempts to access PDMP count if system is unavailable.
Prescription Drug Monitoring Program
PDMP scope and operation:
Board will promulgate rules designating additional controlled substances and other prescription drugs to be tracked.
Supplemental limited-benefit policies are excluded from the mandate requiring coverage of nonpharmacological treatments. Specifically, the statute states that any health benefit plan must provide coverage for nonpharmacological treatment as an alternative to opioids, except supplemental policies covering a specified disease or other limited benefit.
Providers may inform covered persons about their financial responsibility for services; the law prohibits restricting a physical therapist, occupational therapist, or acupuncturist from providing a covered person information on the amount of the covered person’s financial responsibility for those services.
Provider Actions and Requirements
No prior authorization for nonpharmacological alternatives; atypical opioid access
Nonpharmacological treatments required by Colorado law shall not be subject to prior authorization; carriers must also place at least one FDA‑approved atypical opioid for acute or chronic pain on the lowest formulary tier without requiring prior authorization.
- Nonpharmacological treatments as alternatives to opioids shall not require prior authorization.
- A carrier providing prescription drug benefits must provide coverage for at least one FDA‑approved atypical opioid at the lowest formulary tier and not require prior authorization for that atypical opioid.
Step therapy prohibited for atypical opioids
Carriers are prohibited from requiring step therapy for at least one FDA‑approved atypical opioid placed on the lowest formulary tier and may not impose step therapy for any additional FDA‑approved atypical opioids for acute or chronic pain.
- Do not implement step therapy as a condition of coverage for the required atypical opioid on the lowest tier.
- Do not require step therapy for any additional FDA‑approved atypical opioids for acute or chronic pain.
Notify carrier at patient’s initial visit
At the covered person's initial visit, the treating physical therapist, occupational therapist, acupuncturist, or chiropractor must notify the covered person's carrier that the patient has started treatment with that provider.
- Notification must occur at the time of the covered person's initial visit for treatment.
Coverage and prior authorization prohibitions — carrier obligations and enforcement risk
Failure to provide the mandated coverage and to avoid prior authorization or step therapy as required by statute may expose carriers to enforcement; carriers must provide coverage for the specified nonpharmacological services and comply with the statutory prohibitions on prior authorization and step therapy.
- Carriers must provide coverage for nonpharmacological treatments (minimum six visits per modality) and must not require prior authorization for those treatments.
- Carriers providing prescription drug benefits must place at least one FDA‑approved atypical opioid on the lowest formulary tier and must not impose step therapy or prior authorization for that drug (nor step therapy for additional atypical opioids).
Background
The act recognizes the opioid epidemic and promotes safer alternatives by requiring coverage for specified nonpharmacological therapies and by directing carrier formulary policies for certain lower-risk analgesics. It identifies examples of atypical opioids such as buprenorphine, tramadol, and tapentadol as alternatives with different safety profiles, and mandates access and protections (for example, minimum covered visits and prohibition of prior authorization for nonpharmacological treatments) to encourage use of these alternatives.
Definitions
Treatment Modalities
Nonpharmacological therapies (PT, OT, chiropractic, acupuncture)
Coverage criteria for nonpharmacological therapies:
Applies to physical therapy, occupational therapy, chiropractic, acupuncture.
Atypical opioids (buprenorphine, tramadol, tapentadol)
Coverage and placement for atypical opioids:
Visit Minimums and Limits
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