First-of-its-kind law mandates coverage and removes prior authorization for alternatives to opioids (ALTOs)
by Kate Alfano, CMS Director of Communications and Marketing
Featured in the November-December 2021-January 2022 Colorado Medicine.
“The COVID-19 pandemic had an unprecedented impact on substance use and on access to treatment and support options. Social isolation, the pandemic-induced recession, and changes to care delivery brought about by shut-downs contributed to the most significant one-year increase in drug overdose deaths in recent memory.”
This bleak statement from the Colorado Health Institute provides context to some stark facts.
- Opioid overdoses rose by 54 percent in 2020, accounting for nearly two in three overdose deaths in Colorado.
- 1,477 Coloradans died of drug overdoses in 2020 – the most overdose deaths ever recorded in the state, and a 38 percent increase from 2019.
- Fentanyl overdoses became more common, more than doubling between 2019 and 2020 and increasing by 10 times since 2016.
- Existing inequities and the COVID-19 pandemic exacerbated the increase in overdose deaths in communities of color.
- Opioid prescriptions have decreased by 44.4 percent nationwide between 2011 and 2020, including a 6.9 percent decrease from 2019 and 2020.
In essence, as the world turned its attention to the novel COVID-19 pandemic in 2020, the not-novel opioid epidemic worsened. In response, and at the urging of the Colorado Medical Society, Colorado Consortium for Prescription Drug Abuse Prevention (Consortium), Colorado Pain Society (CPS) and others, the 2021 Colorado General Assembly passed legislation to provide help to patients struggling with pain and the physicians who help them manage it, which evidence suggests will help prevent patients from developing a substance use disorder.
Measures in House Bill 21-1276 – sponsored by Rep. Chris Kennedy, Rep. Leslie Herod, Sen. Brittany Pettersen and Sen. Kevin Priola – that CMS strongly supports increase access to alternatives to opioids (ALTOs) by requiring health plans to provide affordable coverage for nonpharmacological pain treatment (six physical therapy, occupational therapy, chiropractic, and acupuncture visits with a cost-sharing amount no more than for a primary care visit) and requiring health plans to provide coverage for at least one atypical opioid at the lowest cost-sharing tier of the plan’s formulary with no requirement for step therapy or prior authorization. In addition, a plan cannot require step therapy for any additional atypical opioids.
CMS expressed strong opposition to provisions in the bill that will continue indefinitely a limit on prescribing opioids to a seven-day supply (with existing exceptions fought for by CMS), direct boards of prescribers to set limits on benzodiazepine prescriptions (with exceptions for which CMS fought), and require prescribers to query the Prescription Drug Monitoring Program each time before prescribing an opioid or a benzodiazepine (again, with exceptions).
“This law is the first of its kind in the country to limit cumbersome and time-consuming prior authorizations, and to make it easier and more affordable to access ALTOs,” said Jonathan Clapp, MD, CPS president and chair of the CMS Substance Use Disorder Committee. “Eliminating prior authorizations in any capacity is a huge victory for physicians who too often feel powerless against payers and their tactics to dictate patient care.”
Clapp encourages physicians to consider using ALTOs first and to take advantage of continuing medical education provided by the Consortium and accredited by CMS. View educational opportunities on the Consortium’s website, www.corxconsortium.org.
CMS will continue to advocate for ways to make it easier for members to treat pain and substance use disorder in patients.
State auditor recommends improvements to PDMP, use by physicians
Colorado’s Prescription Drug Monitoring Program (PDMP) was created in 2008 to electronically track and monitor prescriptions for controlled substances to help prevent their misuse, allow prescribers to review patients’ prescription histories, and help law enforcement and regulatory boards investigate potentially harmful prescribers.
A March 2021 report by State Auditor Kerri L. Hunter, CPA, identified potential areas to improve the effectiveness of the PDMP:
- • Require prescribers to query the PDMP before prescribing each opioid (achieved by HB 21-1276).
- • Enforce the requirements that prescribers and pharmacists register to use and query the PDMP.
- • Enforce statutory limits on opioid prescriptions and develop enforcement mechanisms for noncompliant prescribers.
- • Ensure pharmacies comply with rules to submit data on prescriptions in a timely fashion.
While outside the state audit, for years CMS has strongly recommended improving interoperability with electronic health records (EHRs) and the PDMP, which would aid query functionality for physicians and their practices and reduce the administrative burden for compliance.