Beginning January 1, 2026, patients who have Colorado regulated commercial health insurance and their providers will benefit from the below changes to prior authorization processes.
Covered or Required Alternative Services or Treatment: For denial of a prior authorization request, a carrier must identify relevant alternative services or treatment or treatments that may be a covered benefit or are required before approval. Covered Alternative Drugs: For denial of a prior authorization request for a prescription drug, a carrier must specify which dosages or alternative drugs in the same class of medication are a covered benefit Duration of Approvals: The duration of prior authorization approvals is extended from the current 180 days to a new duration of one year or the length of treatment. Duration of Approvals for Chronic Medications: The duration of prior authorizations for chronic medications will generally be three years. Drugs that cost more than $30,000 annually may be subject to a one-year approval. No Denial for Certain Additional or Related Procedures: A carrier is prohibited from denying coverage for surgical care that was approved but then during surgery requires a medically necessary additional or related covered procedure that would likely harm the patient to delay. Electronic Filing of Prior Authorizations: Each carrier must comply with federal standards to send electronic prior authorizations for services and medications. Insurers will also be required to increase transparency regarding their prior authorization processes. Required Disclosures
Prior Authorization Requirements and Restrictions: Each carrier must post on a publicly facing website all prior authorization requirements and restrictions. Formulary Requirements: Each carrier must post on a publicly facing website prior authorization all formulary requirements in standardized, searchable format for clarity about what drugs are covered. Prior Authorization Outcomes Data: Each carrier must post on a publicly facing website prior authorization data in standardized, searchable format including for each category of service the number of prior authorization requests received, approvals, and denials by category of denial; as well as the number of adverse determinations that were appealed and the results. Finally, insurers must develop alternatives to prior authorizations and attest to removing prior authorization processes that neither promote quality, promote equity or reduce costs. Prior Authorization Removal and Alternative Program
Removal Based on Lack of Quality or Cost Reduction: Each carrier must annually review their list of prior authorization for services and medications and attest to the Division of Insurance that they removed prior authorization requirements that neither promote quality, promote equity or reduce costs. Alternative Exemption Program Requirement: Each carrier must create alternative exemption programs to prior authorization for qualified providers for medical services & prescription drugs. Data on the number of providers offered exemptions through the programs, the types of programs or exemptions offered, and the type of service or drug for which the exemption applied must be publicly posted on a carrier’s website. *Summary prepared for the Colorado Medical Society by Conklin, Cardone, & Rutberg, PC Attorneys at Law