CMS Seeks to Expand Interoperability Requirements for Drug Prior Authorization

Details

The Centers for Medicare and Medicaid Services (CMS) issued a proposed rule on April 10, 2026, titled “2026 CMS Interoperability Standards and Prior Authorization for Drugs.” The goal is to impose enhanced interoperability requirements on payors participating in specific Medicare and Medicaid programs. The key mandates include requiring impacted payors to implement electronic prior authorization systems. Technically, drugs billed under the medical benefit must use the FHIR-based Prior Authorization API, while drugs dispensed through the pharmacy benefit must align with NCPDP data exchange protocols. CMS also clarifies decision timelines (e.g., 1 day for urgent requests, 3 days for routine ones) and mandates that payors provide detailed explanations when a drug prior authorization request is denied. Furthermore, all information related to these processes—including outcomes, details, and denial reasons—must be shared via the Patient Access, Provider Access, and Payer-to-Payer APIs. If finalized, many changes are expected to take effect starting October 1, 2027, significantly altering the data exchange framework in US healthcare IT.