2023 Colorado Revised Statutes › Title 25.5 - HEALTH CARE POLICY AND FINANCING (§§ 25.5-1-101 — 25.5-11-101) › COLORADO MEDICAL ASSISTANCE ACT (§§ 25.5-4-101 — 25.5-6-2001) › Article 5 - COLORADO MEDICAL ASSISTANCE ACT - SERVICES AND PROGRAMS (§§ 25.5-5-101 — 25.5-5-804) › Part 5 - PRESCRIPTION DRUGS (§§ 25.5-5-500.3 — 25.5-5-518) › Section 25.5-5-517 - Prescription drugs for treating mental health disorders or conditions - prior authorization - rules - definitions

(1)
As used in this section, unless the context otherwise requires:
(a)
"Mental health disorder or mental health condition" refers to the mental health disorders described in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders.
(b)
"Prescription drug" has the same meaning as set forth in section 12-280-103.
(c)
"Unsuccessfully treated" refers to the clinically appropriate guidelines used to determine a patient's failure on a medication and may include a lack of efficacy during a six-week medication trial, an allergic reaction, intolerable side effects, significant drug-to-drug interactions, or a known interacting genetic polymorphism that prevents safe preferred medication dosing as attested to by the provider.
(2)
The state department shall not require an adult to be prescribed an antipsychotic prescription drug that is included on the preferred drug list and used to treat a mental health disorder or mental health condition, as indicated on federally approved labels, if:
(a)
During the preceding three hundred sixty-five days, the adult was prescribed and unsuccessfully treated with an antipsychotic prescription drug that is included on the preferred drug list and used to treat a mental health disorder or mental health condition and for which a single claim is paid; or
(b)
The adult is stable on an antipsychotic drug used to treat a mental health disorder or mental health condition that it not included on the preferred drug list.
(3)
This section applies to a fee-for-service medical assistance plan and a health maintenance organization that has a contract with the state department and provides coverage for prescription drugs.
(4)
This section does not prohibit the state department from contracting with a managed care organization for pharmaceutical services offered under the state medical assistance program pursuant to this article 5 and articles 4 and 6 of this title 25.5, if the contract complies with this section.
(5)
This section does not prohibit or discourage the use of a generic drug.
(6)
This section does not prevent the state department from performing a drug utilization review that is necessary for patient safety or to ensure the prescribed use is for a medically accepted indication, as required by section 1927 of the federal "Social Security Act of 1935".
(7)
This section does not prevent the state department from requiring the prescribing provider to electronically attest that the adult meets the requirements of subsection (2)(a) or (2)(b) of this section prior to providing coverage for an antipsychotic drug used to treat a mental health disorder or mental health condition that is not included on the preferred drug list. The attestation must be automatically processed and must automatically override the preferred drug coverage requirement upon the attestation being made.
Added by 2024 Ch. 363,§ 2, eff. 6/3/2024.