Second Regular Session
Seventy-fourth General Assembly
STATE OF COLORADO
INTRODUCED
LLS NO. 24-0202.01 Christy Chase x2008
HOUSE BILL 24-1149
House Committees Senate Committees
Health & Human Services
A BILL FOR AN ACT
C
ONCERNING MODIFICATIONS TO REQUIREMENTS FOR PRIOR101
AUTHORIZATION OF BENEFITS UNDER HEALTH BENEFIT PLANS .102
Bill Summary
(Note: This summary applies to this bill as introduced and does
not reflect any amendments that may be subsequently adopted. If this bill
passes third reading in the house of introduction, a bill summary that
applies to the reengrossed version of this bill will be available at
http://leg.colorado.gov
.)
With regard to prior authorization requirements imposed by
carriers, private utilization review organizations (organizations), and
pharmacy benefit managers (PBMs) for certain health-care services and
prescription drug benefits covered under a health benefit plan, the bill
requires carriers, organizations, and PBMs, as applicable, to adopt a
program, in consultation with participating providers, to eliminate or
HOUSE SPONSORSHIP
Bird and Frizell, Amabile, Armagost, Bacon, Boesenecker, Bottoms, Bradfield, Clifford,
deGruy Kennedy, Duran, English, Froelich, Garcia, Hamrick, Hartsook, Hernandez, Jodeh,
Kipp, Lieder, Lindstedt, Mabrey, McLachlan, Ortiz, Rutinel, Sirota, Snyder, Soper, Taggart,
Titone, Valdez, Velasco, Weinberg, Willford, Wilson, Young
SENATE SPONSORSHIP
Roberts and Kirkmeyer, Ginal, Baisley, Bridges, Buckner, Coleman, Cutter, Gonzales,
Hansen, Hinrichsen, Kolker, Liston, Marchman, Michaelson Jenet, Mullica, Pelton R., Rich,
Van Winkle, Will, Winter F., Zenzinger
Shading denotes HOUSE amendment. Double underlining denotes SENATE amendment.
Capital letters or bold & italic numbers indicate new material to be added to existing law.
Dashes through the words or numbers indicate deletions from existing law. substantially modify prior authorization requirements in a manner that
removes administrative burdens on qualified providers and their patients
with regard to certain health-care services, prescription drugs, or related
benefits based on specified criteria. Additionally, a carrier or organization
is prohibited from denying a claim for a health-care procedure a provider
provides, in addition or related to an approved surgical procedure, under
specified circumstances or from denying an initially approved surgical
procedure on the basis that the provider provided an additional or a
related health-care procedure.
The bill extends the duration of an approved prior authorization for
a health-care service or prescription drug benefit from 180 days to a
calendar year.
Carriers are required to post, on their public-facing websites,
specified information regarding:
! The number of prior authorization requests that are
approved, denied, and appealed;
! The number of prior authorization exemptions or
alternatives to prior authorization requirements provided
pursuant to a program developed and offered by the carrier,
an organization, or a PBM; and
! The prior authorization requirements as applied to
prescription drug formularies for each health benefit plan
the carrier or PBM offers.
The bill applies to conduct occurring on or after January 1, 2026.
Be it enacted by the General Assembly of the State of Colorado:1
SECTION 1. Legislative declaration. (1) The general assembly2
finds and declares that:3
(a) Timely access to necessary health care is of vital importance4
to Coloradans;5
(b) The provider-patient relationship is paramount and should not6
be subject to intrusion by a third party;7
(c) Coloradans and their health-care providers deserve easy access8
to information regarding health insurance benefits so that, together, they9
can determine the proper course of treatment;10
(d) Utilization management processes, such as prior authorization,11
HB24-1149-2- delay care, which, according to thirty-four percent of physicians surveyed1
nationally, leads to serious adverse events for their patients, including2
hospitalization, permanent disability, or even death;3
(e) These outcomes due to delays in timely accessing services and4
prescriptions are known to disproportionately impact historically5
marginalized populations, such as Black and Hispanic patients, furthering6
health disparities in the state;7
(f) Surveys have found that over sixty percent of physicians also8
report that it is difficult to determine whether a prescription medication9
or medical service requires prior authorization, adding burdensome10
administrative steps for health-care providers and patients to understand11
requirements for accessing necessary medical services or prescriptions;12
and13
(g) Health systems spend an average of twenty dollars, for a14
primary care visit, to two hundred fifteen dollars, for an inpatient surgical15
procedure, on administrative tasks to navigate insurer utilization16
management processes like processing prior authorization requests.17
(2) Therefore, it is the intent of the general assembly, by18
establishing transparent prescription formularies and enabling access to19
prior authorization requirements at the point of care delivery; requiring20
posting of data on prior authorization practices; and requiring carriers,21
private utilization review organizations, and pharmacy benefit managers22
to adopt a program that streamlines the administrative process for23
qualifying health-care providers who satisfy certain objective criteria24
regarding quality and appropriateness of care and specialty area and25
experience, to:26
(a) Ensure Coloradans have equitable access to medically27
HB24-1149
-3- necessary care;1
(b) Reduce administrative burdens and costs borne by health-care2
providers; and3
(c) Reduce overall costs to the health-care system.4
SECTION 2. In Colorado Revised Statutes, 10-16-112.5, amend5
(2)(a), (2)(c), (3)(c)(II), (4)(b), (5)(a), (6), and (7)(e); and add (4)(c),6
(4)(d), and (7)(g) as follows:7
10-16-112.5. Prior authorization for health-care services -8
disclosures and notice - determination deadlines - criteria - limits and9
exceptions - definitions - rules - enforcement. (2) Disclosure of10
requirements - notice of changes. (a) (I) A carrier shall make POST11
current prior authorization requirements and restrictions, including12
written, clinical criteria, readily accessible on the carrier's PUBLIC-FACING13
website
IN A READILY ACCESSIBLE, STANDARDIZED, SEARCHABLE FORMAT.14
The prior authorization requirements must be described in detail and in15
clear and easily understandable language.16
(II) If a carrier contracts with a private utilization review17
organization to perform prior authorization for health-care services, the18
organization shall provide its prior authorization requirements and19
restrictions, as required by this subsection (2), to the carrier with whom
20
WHICH the organization contracted, and that carrier shall post the21
organization's prior authorization requirements and restrictions on its22
PUBLIC-FACING website IN THE MANNER REQUIRED BY SUBSECTION23
(2)(a)(I)
OF THIS SECTION.24
(III) When posting prior authorization requirements and
25
restrictions pursuant to this subsection (2)(a) or subsection (2)(b) of this26
section, a carrier is neither required to post nor prohibited from posting27
HB24-1149
-4- the prior authorization requirements and restrictions on a public-facing1
portion of its website.2
(c) (I) A carrier shall post, on a public-facing portion of its3
website, data regarding approvals and denials of prior authorization4
requests, including requests for drug benefits pursuant to section5
10-16-124.5, in a readily accessible,
STANDARDIZED, SEARCHABLE format6
and that include the following: categories, in the aggregate:
7
(A) Provider specialty THE TOTAL NUMBER OF PRIOR8
AUTHORIZATION REQUESTS RECEIVED IN THE IMMEDIATELY PRECEDING9
CALENDAR YEAR IN EACH OF THE FOLLOWING CATEGORIES OF SERVICES :10
M
EDICAL PROCEDURES; DIAGNOSTIC TESTS AND DIAGNOSTIC IMAGES ;11
PRESCRIPTION DRUGS; AND ALL OTHER CATEGORIES OF HEALTH -CARE12
SERVICES OR DRUG BENEFITS FOR WHICH A PRIOR AUTHORIZATION13
REQUEST WAS RECEIVED;14
(B) Medication or diagnostic test or procedure
THE TOTAL15
NUMBER OF PRIOR AUTHORIZATION REQUESTS THAT WERE APPROVED IN16
EACH OF THE CATEGORIES SPECIFIED IN SUBSECTION (2)(c)(I)(A) OF THIS17
SECTION;18
(C) Reason for denial; and THE TOTAL NUMBER OF PRIOR19
AUTHORIZATION REQUESTS FOR WHICH AN ADVERSE DETERMINATION WAS20
ISSUED AND THE SERVICE WAS DENIED IN EACH OF THE CATEGORIES21
SPECIFIED IN SUBSECTION (2)(c)(I)(A) OF THIS SECTION; AND22
(D) Denials specified under subsection (2)(c)(I)(C) of this section23
that are overturned on appeal IN EACH OF THE CATEGORIES SPECIFIED IN24
SUBSECTION (2)(c)(I)(A) OF THIS SECTION, THE TOTAL NUMBER OF25
ADVERSE DETERMINATIONS THAT WERE APPEALED AND WHETHER THE26
DETERMINATION WAS UPHELD OR REVERSED ON APPEAL .27
HB24-1149
-5- (II) An organization OR PBM that provides prior authorization for1
a carrier shall provide the data specified in subsection (2)(c)(I) of this2
section to the carrier with whom WHICH the organization OR PBM3
contracted, and the carrier shall post the organization's
OR PBM'S data on4
its
PUBLIC-FACING website IN THE MANNER REQUIRED BY SUBSECTION5
(2)(c)(I)
OF THIS SECTION.6
(III) Carriers and organizations shall use the data specified in this7
subsection (2)(c) to refine and improve their utilization management8
programs. C
ARRIERS AND ORGANIZATIONS SHALL REVIEW THE LIST OF9
MEDICAL PROCEDURES , DIAGNOSTIC TESTS AND DIAGNOSTIC IMAGES ,10
PRESCRIPTION DRUGS, AND OTHER HEALTH-CARE SERVICES FOR WHICH THE11
CARRIER OR ORGANIZATION REQUIRES PRIOR AUTHORIZATION AT LEAST12
ANNUALLY AND SHALL ELIMINATE THE PRIOR AUTHORIZATION13
REQUIREMENTS FOR THOSE PROCEDURES , DIAGNOSTIC TESTS AND14
DIAGNOSTIC IMAGES, PRESCRIPTION DRUGS, OR OTHER HEALTH-CARE15
SERVICES FOR WHICH PRIOR AUTHORIZATION REQUESTS ARE APPROVED16
WITH SUCH FREQUENCY AS TO DEMONSTRATE THAT THE PRIOR17
AUTHORIZATION REQUIREMENT NEITHER PROMOTES HEALTH -CARE18
QUALITY OR EQUITY NOR REDUCES HEALTH -CARE SPENDING TO A DEGREE19
SUFFICIENT TO JUSTIFY THE ADMINISTRATIVE COSTS TO THE CARRIER OR20
ORGANIZATION. EACH CARRIER AND ORGANIZATION SHALL ANNUALLY21
ATTEST THAT IT HAS COMPLETED THE REVIEW REQUIRED BY THIS22
SUBSECTION (2)(c)(III) AND HAS ELIMINATED PRIOR AUTHORIZATION23
REQUIREMENTS CONSISTENT WITH THE REQUIREMENTS OF THIS24
SUBSECTION (2)(c)(III).25
(IV) A
CARRIER SHALL POST, ON A PUBLIC-FACING PORTION OF ITS26
WEBSITE, IN A READILY ACCESSIBLE , STANDARDIZED, SEARCHABLE27
HB24-1149
-6- FORMAT, DATA ON THE NUMBER OF EXEMPTIONS FROM PRIOR1
AUTHORIZATION REQUIREMENTS OR ALTERNATIVES TO PRIOR2
AUTHORIZATION REQUIREMENTS PROVIDED PURSUANT TO A PROGRAM3
ADOPTED BY THE CARRIER , ORGANIZATION, OR PBM PURSUANT TO4
SUBSECTION (4)(b)(II) OF THIS SECTION OR SECTION 10-16-124.5 (5.5), AS5
APPLICABLE. THE CARRIER SHALL INCLUDE THE FOLLOWING DATA :6
(A) T
HE NUMBER OF PROVIDERS OFFERED AN EXEMPTION OR7
ALTERNATIVE PROGRAM , INCLUDING THEIR SPECIALTY AREAS;8
(B) T
HE NUMBER AND CATEGORIZED TYPES OF EXEMPTIONS OR9
ALTERNATIVE PROGRAMS OFFERED TO PROVIDERS ; AND10
(C) T
HE PRESCRIPTION DRUG, DIAGNOSTIC TEST, PROCEDURE, OR11
OTHER HEALTH-CARE SERVICE FOR WHICH AN EXEMPTION OR12
ALTERNATIVE PROGRAM WAS OFFERED .13
(V) T
HE COMMISSIONER SHALL ADOPT RULES TO IMPLEMENT14
SUBSECTIONS (2)(c)(I) AND (2)(c)(IV) OF THIS SECTION TO ENSURE THAT15
THE DATA FIELDS REQUIRED TO BE POSTED PURSUANT TO SUBSECTIONS16
(2)(c)(I)
AND (2)(c)(IV) OF THIS SECTION ARE PRESENTED CONSISTENTLY17
BY CARRIERS.18
(3) Nonurgent and urgent health-care services - timely19
determination - notice of determination - deemed approved. (c) (II) If20
the carrier or organization denies a prior authorization request based on21
a ground specified in section 10-16-113 (3)(a), the notification is subject22
to the requirements of section 10-16-113 (3)(a) and commissioner rules23
adopted pursuant to that section and must include information concerning24
whether the carrier or organization requires an alternative treatment, test,25
procedure, or medication
AND WHAT ALTERNATIVE SERVICES OR26
MEDICATIONS WOULD BE APPROVED AS A COVERED BENEFIT UNDER THE27
HB24-1149
-7- HEALTH BENEFIT PLAN. A CARRIER'S OR ORGANIZATION'S COMPLIANCE1
WITH THIS SUBSECTION (3)(c)(II) DOES NOT CONSTITUTE THE PRACTICE OF2
MEDICINE.3
(4) Criteria, limits, and exceptions. (b) (I) Carriers and4
organizations shall consider limiting the use of prior authorization to5
providers whose prescribing or ordering patterns differ significantly from6
the patterns of their peers after adjusting for patient mix and other7
relevant factors and present opportunities for improvement in adherence8
to the carrier's or organization's prior authorization requirements.9
(II) (A) NO LATER THAN JANUARY 1, 2026, a carrier or AN10
organization may offer providers with a history of adherence to the11
carrier's or organization's prior authorization requirements at least one12
alternative to prior authorization, including an exemption from prior13
authorization requirements for a provider that has at least an eighty14
percent approval rate of prior authorization requests over the immediately15
preceding twelve months. SHALL ADOPT A PROGRAM , DEVELOPED IN16
CONSULTATION WITH PROVIDERS PARTICIPATING WITH THE CARRIER , TO17
ELIMINATE OR SUBSTANTIALLY MODIFY PRIOR AUTHORIZATION18
REQUIREMENTS IN A MANNER THAT REMOVES THE ADMINISTRATIVE19
BURDEN FOR QUALIFIED PROVIDERS , AS DEFINED UNDER THE PROGRAM ,20
AND THEIR PATIENTS FOR CERTAIN HEALTH-CARE SERVICES AND RELATED21
BENEFITS BASED ON ANY OF THE FOLLOWING :22
(A) T
HE PERFORMANCE OF PROVIDERS WITH RESPECT TO23
ADHERENCE TO NATIONALLY RECOGNIZED , EVIDENCE-BASED MEDICAL24
GUIDELINES, APPROPRIATENESS, EFFICIENCY, AND OTHER QUALITY25
CRITERIA; AND26
(B) P
ROVIDER SPECIALTY, EXPERIENCE, OR OTHER OBJECTIVE27
HB24-1149
-8- FACTORS; EXCEPT THAT ELIGIBILITY FOR THE PROGRAM MUST NOT BE1
LIMITED BY PROVIDER SPECIALTY.2
(III) A
PROGRAM DEVELOPED PURSUANT TO SUBSECTION (4)(b)(II)3
OF THIS SECTION:4
(A) M
UST NOT REQUIRE QUALIFIED PROVIDERS TO REQUEST5
PARTICIPATION IN THE PROGRAM; AND6
(B) M
AY INCLUDE LIMITING THE USE OF PRIOR AUTHORIZATION TO7
PROVIDERS WHOSE PRESCRIBING OR ORDERING PATTERNS DIFFER8
SIGNIFICANTLY FROM THE PATTERNS OF THEIR PEERS AFTER ADJUSTING9
FOR PATIENT MIX AND OTHER RELEVANT FACTORS AND IN ORDER TO10
PRESENT THOSE PROVIDERS WITH OPPORTUNITIES FOR IMPROVEMENT IN11
ADHERENCE TO THE CARRIER'S OR ORGANIZATION'S PRIOR AUTHORIZATION12
REQUIREMENTS.13
(IV) At least annually, a carrier or
AN organization shall:14
(A) Reexamine a provider's prescribing or ordering patterns; and
15
(B) Reevaluate the provider's status for exemption from or other16
alternative to prior authorization requirements OR FOR INCLUSION IN THE17
PROGRAM DEVELOPED pursuant to this subsection (4)(b)(II) OF THIS18
SECTION; AND19
(B) (C) The carrier or organization shall inform NOTIFY the20
provider of the provider's
STATUS FOR exemption status and provide
21
information on the data considered as part of its reexamination of the22
provider's prescribing or ordering patterns for the twelve-month period of23
review OR INCLUSION IN THE PROGRAM.24
(V) A
PROGRAM DEVELOPED PURSUANT TO SUBSECTION (4)(b)(II)25
OF THIS SECTION MUST INCLUDE PROCEDURES FOR A PROVIDER TO26
REQUEST:27
HB24-1149
-9- (A) AN EXPEDITED, INFORMAL RESOLUTION OF A CARRIER'S OR AN1
ORGANIZATION'S FAILURE OR REFUSAL TO INCLUDE THE PROVIDER IN THE2
PROGRAM; AND3
(B) I
F THE MATTER IS NOT RESOLVED THROUGH INFORMAL4
RESOLUTION, A BINDING, INDEPENDENT EXTERNAL REVIEW OF THE5
CARRIER'S OR ORGANIZATION'S FAILURE OR REFUSAL TO INCLUDE THE6
PROVIDER IN THE PROGRAM USING A REVIEWER APPOINTED BY THE7
COMMISSIONER FROM THE LIST OF ARBITRATORS APPROVED PURSUANT TO8
SECTION 10-16-704 (15)(b). THE PROVIDER AND THE CARRIER OR9
ORGANIZATION SHALL SUBMIT WRITTEN MATERIALS TO THE REVIEWER10
WITHIN THIRTY DAYS AFTER THE REVIEWER 'S APPOINTMENT, AND THE11
REVIEWER SHALL ISSUE A DETERMINATION WITHIN FORTY -FIVE DAYS12
AFTER SUCH APPOINTMENT.13
(c) I
F A CARRIER AND A PROVIDER ARE ENGAGED IN A14
VALUE-BASED REIMBURSEMENT ARRANGEMENT FOR PARTICULAR15
HEALTH-CARE SERVICES OR PARTICULAR POLICYHOLDERS , THE CARRIER16
SHALL NOT IMPOSE ANY PRIOR AUTHORIZATION REQUIREMENTS FOR ANY17
PARTICULAR HEALTH -CARE SERVICE THAT IS INCLUDED IN THE18
VALUE-BASED REIMBURSEMENT ARRANGEMENT .19
(d) (I) W
HEN A CARRIER OR AN ORGANIZATION APPROVES A PRIOR20
AUTHORIZATION REQUEST FOR A SURGICAL PROCEDURE FOR WHICH PRIOR21
AUTHORIZATION IS REQUIRED, THE CARRIER OR ORGANIZATION SHALL NOT22
DENY A CLAIM FOR AN ADDITIONAL OR A RELATED HEALTH -CARE23
PROCEDURE IDENTIFIED DURING THE AUTHORIZED SURGICAL PROCEDURE24
IF:25
(A) T
HE PROVIDER, WHILE PROVIDING THE APPROVED SURGICAL26
PROCEDURE TO TREAT THE COVERED PERSON , DETERMINES, IN27
HB24-1149
-10- ACCORDANCE WITH GENERALLY ACCEPTED STANDARDS OF MEDICAL1
PRACTICE, THAT PROVIDING A RELATED HEALTH -CARE PROCEDURE,2
INSTEAD OF OR IN ADDITION TO THE APPROVED SURGICAL PROCEDURE , IS3
MEDICALLY NECESSARY AS PART OF THE TREATMENT OF THE COVERED4
PERSON AND THAT, IN THE PROVIDER'S CLINICAL JUDGMENT, TO INTERRUPT5
OR DELAY THE PROVISION OF CARE TO THE COVERED PERSON IN ORDER TO6
OBTAIN PRIOR AUTHORIZATION FOR THE ADDITIONAL OR RELATED7
HEALTH-CARE PROCEDURE WOULD NOT BE MEDICALLY ADVISABLE ;8
(B) T
HE ADDITIONAL OR RELATED HEALTH -CARE PROCEDURE IS A9
COVERED BENEFIT UNDER THE COVERED PERSON 'S HEALTH BENEFIT PLAN;10
(C) T
HE ADDITIONAL OR RELATED HEALTH -CARE PROCEDURE IS11
NOT EXPERIMENTAL OR INVESTIGATIONAL ;12
(D) A
FTER COMPLETING THE ADDITIONAL OR RELATED13
HEALTH-CARE PROCEDURE AND BEFORE SUBMITTING A CLAIM FOR14
PAYMENT, THE PROVIDER NOTIFIES THE CARRIER OR ORGANIZATION THAT15
THE PROVIDER PERFORMED THE ADDITIONAL OR RELATED HEALTH -CARE16
PROCEDURE AND INCLUDES IN THE NOTICE THE INFORMATION REQUIRED17
UNDER THE CARRIER 'S OR ORGANIZATION 'S CURRENT PRIOR18
AUTHORIZATION REQUIREMENTS POSTED IN ACCORDANCE WITH19
SUBSECTION (2)(a)(I) OF THIS SECTION; AND20
(E) T
HE PROVIDER IS COMPLIANT WITH THE CARRIER 'S OR21
ORGANIZATION'S POST-SERVICE CLAIMS PROCESS, INCLUDING SUBMISSION22
OF THE CLAIM WITHIN THE CARRIER 'S OR ORGANIZATION'S REQUIRED23
TIMELINE FOR CLAIMS SUBMISSIONS.24
(II) W
HEN A PROVIDER PROVIDES AN ADDITIONAL OR A RELATED25
HEALTH-CARE PROCEDURE AS DESCRIBED IN THIS SUBSECTION (4)(d), THE26
CARRIER OR ORGANIZATION SHALL NOT DENY THE CLAIM FOR THE INITIAL27
HB24-1149
-11- SURGICAL PROCEDURE FOR WHICH THE CARRIER OR ORGANIZATION1
APPROVED A PRIOR AUTHORIZATION REQUEST ON THE BASIS THAT THE2
PROVIDER PROVIDED THE ADDITIONAL OR RELATED HEALTH -CARE3
PROCEDURE.4
(5) Duration of approval. (a) Upon approval by the carrier or5
organization, a prior authorization is valid for at least one hundred eighty6
days CALENDAR YEAR after the date of approval and continues for the7
duration of the authorized course of treatment. Except as provided in8
subsection (5)(b) of this section, once approved, a carrier or
AN9
organization shall not retroactively deny the prior authorization request10
for a health-care service.11
(6) Rules - enforcement. (a) The commissioner may adopt rules12
as necessary to implement this section.13
(b) T
HE COMMISSIONER MAY ENFORCE THE REQUIREMENTS OF THIS14
SECTION AND IMPOSE A PENALTY OR OTHER REMEDY AGAINST A PERSON15
THAT VIOLATES THIS SECTION.16
(7) Definitions. As used in this section:17
(e) "Private utilization review organization" or "organization" has
18
the same meaning as set forth MEANS A PRIVATE UTILIZATION REVIEW19
ORGANIZATION, AS DEFINED in section 10-16-112 (1)(a), THAT HAS A20
CONTRACT WITH AND PERFORMS PRIOR AUTHORIZATION ON BEHALF OF A21
CARRIER.22
(g) "V
ALUE-BASED REIMBURSEMENT " MEANS REIMBURSEMENT23
THAT:24
(I) T
IES A PAYMENT FOR THE PROVISION OF HEALTH -CARE25
SERVICES TO THE QUALITY OF HEALTH CARE PROVIDED ;26
(II) R
EWARDS A PROVIDER FOR EFFICIENCY AND EFFECTIVENESS ;27
HB24-1149
-12- AND1
(III) M
AY IMPOSE A RISK-SHARING REQUIREMENT ON A PROVIDER2
FOR HEALTH-CARE SERVICES THAT DO NOT MEET THE CARRIER 'S3
REQUIREMENTS FOR QUALITY , EFFECTIVENESS, AND EFFICIENCY.4
SECTION 3. In Colorado Revised Statutes, 10-16-124.5, amend5
(3)(b) introductory portion, (5), and (6); repeal (4); and add (3.5), (5.5),6
(6.5), and (8)(c) as follows:7
10-16-124.5. Prior authorization form - drug benefits - rules8
of commissioner - definitions - repeal. (3) (b) In developing the9
uniform prior authorization process, the commissioner shall take into10
consideration the recommendations, if any, of the work group established
11
pursuant to subsection (4) of this section and the following:12
(3.5) (a) O
N AND AFTER JANUARY 1, 2026, A CARRIER SHALL POST13
ON THE CARRIER'S PUBLIC-FACING WEBSITE, IN A READILY ACCESSIBLE,14
STANDARDIZED, SEARCHABLE FORMAT , PRIOR AUTHORIZATION15
REQUIREMENTS AS APPLICABLE TO THE PRESCRIPTION DRUG FORMULARY16
FOR EACH HEALTH BENEFIT PLAN THE CARRIER OFFERS , INCLUDING THE17
FOLLOWING INFORMATION :18
(I) T
HE HEALTH BENEFIT PLAN TO WHICH THE FORMULARY19
APPLIES;20
(II) E
ACH PRESCRIPTION DRUG THAT IS COVERED UNDER THE21
HEALTH BENEFIT PLAN, INCLUDING BOTH GENERIC AND BRAND -NAME22
VERSIONS OF A PRESCRIPTION DRUG;23
(III) A
NY PRESCRIPTION DRUGS ON THE FORMULARY THAT ARE24
PREFERRED OVER OTHER PRESCRIPTION DRUGS OR ANY ALTERNATIVE25
PRESCRIPTION DRUGS THAT DO NOT REQUIRE PRIOR AUTHORIZATION ;26
(IV) A
NY EXCLUSIONS FROM OR RESTRICTIONS ON COVERAGE ,27
HB24-1149
-13- INCLUDING:1
(A) A
NY TIERING STRUCTURE, INCLUDING COPAYMENT AND2
COINSURANCE REQUIREMENTS ;3
(B) P
RIOR AUTHORIZATION, STEP THERAPY, AND OTHER4
UTILIZATION MANAGEMENT CONTROLS ;5
(C) Q
UANTITY LIMITS; AND6
(D) W
HETHER ACCESS IS DEPENDENT UPON THE LOCATION WHERE7
A PRESCRIPTION DRUG IS OBTAINED OR ADMINISTERED ; AND8
(V) T
HE APPEAL PROCESS FOR A DENIAL OF COVERAGE OR9
ADVERSE DETERMINATION FOR AN ITEM OR SERVICE FOR A PRESCRIPTION10
DRUG.11
(b) T
HE COMMISSIONER SHALL ADOPT RULES AS NECESSARY TO12
IMPLEMENT THIS SUBSECTION (3.5).13
(4) (a) Within thirty days after May 15, 2013, the commissioner
14
shall establish a work group comprised of representatives of:15
(I) The department of regulatory agencies;16
(II) Local and national carriers;17
(III) Captive and noncaptive pharmacy benefit management firms;18
(IV) Providers, including hospitals, physicians, advanced practice19
registered nurses with prescriptive authority, and pharmacists;20
(V) Drug manufacturers;21
(VI) Medical practice managers;22
(VII) Consumers; and23
(VIII) Other stakeholders deemed appropriate by the24
commissioner.25
(b) The work group shall assist the commissioner in developing26
the prior authorization process and shall make recommendations to the27
HB24-1149
-14- commissioner on the items set forth in paragraph (b) of subsection (3) of1
this section. The work group shall report its recommendations to the2
commissioner no later than six months after the commissioner appoints3
the work group members. Regardless of whether the work group submits4
recommendations to the commissioner, the commissioner shall not delay5
or extend the deadline for the adoption of rules creating the prior6
authorization process as specified in paragraph (a) of subsection (3) of7
this section.8
(5) (a) Notwithstanding any other provision of law, on and after9
January 1, 2015 AND EXCEPT AS PROVIDED IN SUBSECTIONS (5)(b), (5)(c),10
AND (5.5) OF THIS SECTION, every prescribing provider shall use the prior11
authorization process developed pursuant to subsection (3) of this section12
to request prior authorization for coverage of drug benefits, and every13
carrier and pharmacy benefit management firm shall use that process for14
prior authorization for drug benefits.15
(b) (I) A
CARRIER OR PBM THAT PROVIDES DRUG BENEFITS UNDER16
A HEALTH BENEFIT PLAN SHALL NOT IMPOSE PRIOR AUTHORIZATION17
REQUIREMENTS UNDER THE HEALTH BENEFIT PLAN FOR A DRUG THAT IS18
APPROVED BY THE FDA AND THAT IS A CHRONIC MAINTENANCE DRUG IF19
THE CARRIER OR PBM HAS PREVIOUSLY APPROVED A PRIOR20
AUTHORIZATION FOR THE COVERED PERSON FOR USE OF THE CHRONIC21
MAINTENANCE DRUG.22
(II) A
S USED IN THIS SUBSECTION (5)(b), "CHRONIC MAINTENANCE23
DRUG" HAS THE MEANING SET FORTH IN SECTION 12-280-103 (9.5).24
(c) I
F A CARRIER OR PBM AND A PROVIDER ARE ENGAGED IN A25
VALUE-BASED REIMBURSEMENT ARRANGEMENT FOR PARTICULAR26
PRESCRIPTION DRUGS OR PARTICULAR POLICYHOLDERS , THE CARRIER27
HB24-1149
-15- SHALL NOT IMPOSE ANY PRIOR AUTHORIZATION REQUIREMENTS FOR ANY1
PARTICULAR PRESCRIPTION DRUG THAT IS INCLUDED IN THE VALUE -BASED2
REIMBURSEMENT ARRANGEMENT .3
(5.5) (a) N
O LATER THAN JANUARY 1, 2026, A CARRIER OR PBM4
SHALL ADOPT A PROGRAM, DEVELOPED IN CONSULTATION WITH PROVIDERS5
PARTICIPATING WITH THE CARRIER , TO ELIMINATE OR SUBSTANTIALLY6
MODIFY PRIOR AUTHORIZATION REQUIREMENTS IN A MANNER THAT7
REMOVES THE ADMINISTRATIVE BURDEN FOR QUALIFIED PROVIDERS , AS8
DEFINED UNDER THE PROGRAM , AND THEIR PATIENTS FOR CERTAIN9
PRESCRIPTION DRUGS AND RELATED DRUG BENEFITS BASED ON ANY OF THE10
FOLLOWING:11
(I) T
HE PERFORMANCE OF PROVIDERS WITH RESPECT TO12
ADHERENCE TO NATIONALLY RECOGNIZED , EVIDENCE-BASED MEDICAL13
GUIDELINES, APPROPRIATENESS, EFFICIENCY, AND OTHER QUALITY14
CRITERIA; AND15
(II) P
ROVIDER SPECIALTY, EXPERIENCE, OR OTHER OBJECTIVE16
FACTORS; EXCEPT THAT ELIGIBILITY FOR THE PROGRAM MUST NOT BE17
LIMITED BY PROVIDER SPECIALTY.18
(b) A
PROGRAM DEVELOPED PURSUANT TO SUBSECTION (5.5)(a) OF19
THIS SECTION:20
(I) M
UST NOT REQUIRE QUALIFIED PROVIDERS TO REQUEST21
PARTICIPATION IN THE PROGRAM; AND22
(II) M
AY INCLUDE LIMITING THE USE OF PRIOR AUTHORIZATION TO23
PROVIDERS WHOSE PRESCRIBING OR ORDERING PATTERNS DIFFER24
SIGNIFICANTLY FROM THE PATTERNS OF THEIR PEERS AFTER ADJUSTING25
FOR PATIENT MIX AND OTHER RELEVANT FACTORS AND IN ORDER TO26
PRESENT THOSE PROVIDERS WITH OPPORTUNITIES FOR IMPROVEMENT IN27
HB24-1149
-16- ADHERENCE TO THE CARRIER'S OR ORGANIZATION'S PRIOR AUTHORIZATION1
REQUIREMENTS.2
(c) A
T LEAST ANNUALLY, A CARRIER OR PBM SHALL:3
(I) R
EEXAMINE A PROVIDER 'S PRESCRIBING OR ORDERING4
PATTERNS;5
(II) R
EEVALUATE THE PROVIDER'S STATUS FOR EXEMPTION FROM6
PRIOR AUTHORIZATION REQUIREMENTS OR FOR INCLUSION IN THE7
PROGRAM DEVELOPED PURSUANT TO SUBSECTION (5.5)(a) OF THIS8
SECTION; AND9
(III) N
OTIFY THE PROVIDER OF THE PROVIDER 'S STATUS FOR10
EXEMPTION OR INCLUSION IN THE PROGRAM .11
(d) A
PROGRAM DEVELOPED PURSUANT TO SUBSECTION (5.5)(a) OF12
THIS SECTION MUST INCLUDE PROCEDURES FOR A PROVIDER TO REQUEST :13
(A) A
N EXPEDITED, INFORMAL RESOLUTION OF A CARRIER 'S OR14
PBM'
S FAILURE OR REFUSAL TO INCLUDE THE PROVIDER IN THE PROGRAM ;15
AND16
(B) I
F THE MATTER IS NOT RESOLVED THROUGH INFORMAL17
RESOLUTION, A BINDING, INDEPENDENT EXTERNAL REVIEW OF THE18
CARRIER'S OR PBM'S FAILURE OR REFUSAL TO INCLUDE THE PROVIDER IN19
THE PROGRAM USING A REVIEWER APPOINTED BY THE COMMISSIONER20
FROM THE LIST OF ARBITRATORS APPROVED PURSUANT TO SECTION21
10-16-704 (15)(b). T
HE PROVIDER AND THE CARRIER OR PBM SHALL22
SUBMIT WRITTEN MATERIALS TO THE REVIEWER WITHIN THIRTY DAYS23
AFTER THE REVIEWER'S APPOINTMENT, AND THE REVIEWER SHALL ISSUE24
A DETERMINATION WITHIN FORTY -FIVE DAYS AFTER SUCH APPOINTMENT .25
(6) Upon approval by the carrier or pharmacy benefit management26
firm, a prior authorization is valid for at least one hundred eighty days
27
HB24-1149
-17- CALENDAR YEAR after the date of approval. If, as a result of a change to1
the carrier's formulary, the drug for which the carrier or pharmacy benefit2
management firm has provided prior authorization is removed from the3
formulary or moved to a less preferred tier status, the change in the status4
of the previously approved drug does not affect a covered person who5
received prior authorization before the effective date of the change for the6
remainder of the covered person's plan year. Nothing in this subsection7
(6) limits the ability of a carrier or pharmacy benefit management firm,8
in accordance with the terms of the health benefit plan, to substitute a9
generic drug, with the prescribing provider's approval and patient's10
consent, for a previously approved brand-name drug.11
(6.5) T
HE COMMISSIONER MAY ENFORCE THE REQUIREMENTS OF12
THIS SECTION AND IMPOSE A PENALTY OR OTHER REMEDY AGAINST A13
PERSON THAT VIOLATES THIS SECTION.14
(8) As used in this section:15
(c) "V
ALUE-BASED REIMBURSEMENT " MEANS REIMBURSEMENT16
THAT:17
(I) T
IES A PAYMENT FOR THE PROVISION OF HEALTH -CARE18
SERVICES TO THE QUALITY OF HEALTH CARE PROVIDED ;19
(II) R
EWARDS A PROVIDER FOR EFFICIENCY AND EFFECTIVENESS ;20
AND21
(III) M
AY IMPOSE A RISK-SHARING REQUIREMENT ON A PROVIDER22
FOR HEALTH-CARE SERVICES THAT DO NOT MEET THE CARRIER 'S23
REQUIREMENTS FOR QUALITY , EFFECTIVENESS, AND EFFICIENCY.24
SECTION 4. Act subject to petition - effective date -25
applicability. (1) This act takes effect at 12:01 a.m. on the day following26
the expiration of the ninety-day period after final adjournment of the27
HB24-1149
-18- general assembly; except that, if a referendum petition is filed pursuant1
to section 1 (3) of article V of the state constitution against this act or an2
item, section, or part of this act within such period, then the act, item,3
section, or part will not take effect unless approved by the people at the4
general election to be held in November 2024 and, in such case, will take5
effect on the date of the official declaration of the vote thereon by the6
governor.7
(2) This act applies to conduct occurring on or after January 1,8
2026.9
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