CMS Proposes Major Changes to Drug Prior Authorization Processes: What You Need To Know

Details

On April 14, 2026, the Centers for Medicare and Medicaid Services (CMS), jointly with the Office of the National Coordinator for Health Information Technology, published a proposed rule. This rule aims to improve electronic health care data exchange and streamline prior authorization processes to reduce waiting periods and barriers to timely access to critical treatments. The proposal is part of a broader regulatory push to transform how drug PA and healthcare interoperability are managed across federal programs. Key changes include: 1. **Electronic PA for All Drugs:** All impacted payers must support electronic PA for every required drug by October 1, 2027. For medical benefits, this requires an API that can transmit requests/decisions; for pharmacy benefits, it mandates supporting the NCPDP SCRIPT standard. 2. **Decision Timelines and Reasons:** QHP issuers face shorter decision timeframes (standard: no later than 72 hours; expedited: no later than 24 hours). Furthermore, all payers must provide a specific reason for any drug PA denial to the prescriber. 3. **Public Reporting:** All impacted payers are required to publicly post detailed PA metrics on their websites starting in 2028 (based on 2027 data), including approval/denial rates and average/median decision times. These changes represent a significant structural shift, mandating technical interoperability standards (like APIs and NCPDP SCRIPT) and increasing transparency across the US healthcare system.