Payers Must Speed Up Drug Prior Authorization: CMS Proposes New Rule

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The Centers for Medicare & Medicaid Services (CMS) released the '2026 CMS Interoperability Standards and Prior Authorization for Drugs Proposed Rule,' requiring payers to address drug prior authorization processes. This new rule extends coverage beyond non-drug items, which were the focus of a 2024 final rule. Specifically, certain insurers would be required to make prior authorization decisions for covered outpatient drugs no later than 24 hours after receiving a request. CMS proposes compliance dates starting October 1, 2027. Furthermore, the proposal mandates payers to update health information technology standards and report interoperability API endpoints and usage metrics. This builds upon previous requirements (2020 and 2024 final rules) that mandated Medicare Advantage organizations and others to implement APIs such as Patient Access, Provider Directory, Provider Access, Payer-to-Payer, and Prior Authorization. This development highlights the ongoing policy push for data exchange efficiency and process streamlining within US healthcare IT.