Weekly Policy Blog: CBSA Supports Drug Coverage for Serious Mental Illness Bill (HB23-1130)

CBSA supports HB23-1130, a bill that aims to help people suffering from a serious mental illness by addressing private payers’ step therapy requirements and Medicaid’s Preferred Drug List review process. These are both “[b]arriers impeding timely access to cutting-edge and physician-recommended psychiatric treatments,” as bill sponsor Representative Dafna Michaelson Jenet explained in an opinion piece in the Denver Post. She is sponsoring the bill along with Assistant Senate Majority Leader Robert Rodriguez. HB23-1130 will be heard in the House Health & Insurance Committee on February 21. 

HB23-1130 is a two-part bill that:  

(1) would ensure patients diagnosed with a serious mental illness are only required by their health insurance plan to try one prescription drug, as part of a step therapy process, prior to their insurance covering the drug recommended by their provider, and  

(2) would require the Colorado Department of Health Care Policy & Financing (HCPF) to expedite the Medicaid Drug Utilization Review Board (DURB) process from 120 days to 90 days so newly available serious mental illness drugs are reviewed for coverage under Medicaid and Preferred Drug List (PDL) inclusion within 90 days of the drug’s approval by the FDA.

Mental Health Crisis 

There is a mental health crisis in Colorado and across the country: 

  • According to the CDC, one in five Americans received treatment for their mental health in 2020, with 16% being prescribed medication. 
  • A report from Mental Health America found that 23% of adults in Colorado suffered from a mental illness in 2022. 
  • According to the Kaiser Family Foundation, nearly one-third of Coloradans experienced symptoms of anxiety or depression in 2021. 
  • According to Brain Health Colorado, the prevalence of mental illness among Colorado adults is among the highest in the country, with Colorado’s rates of mental health and substance abuse disorders ranking among the six highest. 

In addition, Brain Health Colorado illustrates the major problems with coverage for and access to mental health treatment: 

  • 53% of Colorado adults with a mental illness do not receive treatment.
  • 31% of Colorado adults reported they were not able to receive the treatment they needed due to factors such as lack of insurance coverage, a shortage of psychiatrists, lack of available treatment types, a disconnect between primary care systems and behavioral health systems, and insufficient finances to cover costs. 
  • 40% of Colorado youth suffering from a major depressive episode did not receive treatment.

Barriers to Treatment: Step Therapy 

Patients with a serious mental illness may encounter a variety of barriers to treatment. One of those barriers is called “step therapy,” which is a process imposed by a patient’s insurance plan that requires the patient to go through a series of multi-step, “fail-first” hurdles. The patient must try one or more medications mandated by their insurance carrier before their insurance plan will cover the drug actually prescribed by the patient’s provider. This process of forcing patients to verify that other drugs are ineffective or inadequate “drive[s] every doctor crazy,” according to the American Medical Association. It can be dangerous for patients because it delays their access to the treatment deemed most appropriate by their own provider, “sometimes in cases when the patient has already unsuccessfully tried the therapy under a previous insurance plan.” This can prolong and worsen health issues, needlessly subject those already suffering from a serious mental illness to serious side effects, and ultimately cause patients to abandon seeking treatment altogether. 

While insurance companies argue that step therapy can save money by putting a subset of patients on cheaper, alternative drugs, Representative Michaelson Jenet argues that “the detriments of this insurance practice unduly harm patients who do not find success…The treatment the provider recommends may be more expensive, but just like physical health, I trust my medical provider to make the best and most informed decisions about what medicines I should take.”

Barriers to Treatment: Medicaid’s Preferred Drug List Review Process 

As Brain Health Colorado explains, under Colorado’s Medicaid program, drugs newly approved by the FDA are subject to review by HCPF in collaboration with the Pharmacy & Therapeutics Committee and the DURB—which assist HCPF in determining Medicaid Preferred Drug List (PDL) status and prior authorization criteria. PDL review process rules stipulate that access to these new drugs may be limited by prior authorization requirements until review is completed. Colorado law does not establish a timeframe within which this review must take place, and the process can take six months to a year depending on the drug class. This delays treatment for Medicaid patients with a serious mental illness who are awaiting access to cutting-edge drugs.  

As Brain Health Colorado further explains, although HCPF has regulations that provide for a “preliminary evaluation” of new drugs in PDL classes within 30 days of commercial availability, other regulations could continue to make such drugs subject to prior authorization until the regular class-wide review, which can take up to a year.

What HB23-1130 Does 

For commercial health insurance plans regulated by the state, HB23-1130 limits step therapy to one step for patients with a serious mental illness, which includes bipolar disorders, depression in childhood and adolescence, major depressive disorders, obsessive-compulsive disorders, paranoid and other psychotic disorders, schizoaffective disorders, and schizophrenia. “If a carrier, a private utilization review organization, or a PBM require step therapy, the step therapy may only require a covered person to try one prescription drug other that the drug prescribed by the provider prior to providing coverage to the covered person for the drug prescribed by the covered person’s provider.” 

For Colorado’s Medicaid program, HB23-1130 codifies a more straightforward approach for PDL reviews of drugs to treat serious mental illnesses under which such drugs must undergo a full review within 90 days of FDA approval: “…the state board shall require review for coverage of a new drug approved by the [FDA] for a serious mental illness within ninety days after the approval of the drug.”

CBSA’s Advocacy Efforts  

The CBSA Policy + Advocacy team will collaborate with partners and policymakers to advocate for the passage of HB23-1130 as part of our work to promote policies that improve coverage for and access to groundbreaking treatments by removing unnecessary coverage barriers and reducing delays to treatment (see CBSA’s Policy Priorities). 

To get involved with CBSA’s advocacy efforts or talk about your concerns, perspective, or position on a bill, please contact CBSA’s Vice President and Counsel for Policy + Advocacy, Amy Goodman.

Categories: CBSA News