CMS proposes drug prior‑auth APIs
CMS and ONC put forward a 511‑page proposal to require electronic prior‑authorization APIs for drugs across Medicare Advantage, Medicaid managed care, CHIP and exchange plans. The proposal also asks issuers to report API‑related metrics and aligns drug prior‑auth rules with earlier standards for non‑drug items and services (Federal Register:: Medicare and Medicaid Programs; Patient Protection and Affordable Care Act; Interoperability Standards and Prior Authorization for Drugs) (CMS Proposes Drug Prior Authorization Interoperability Rule | GovPing).
The Centers for Medicare and Medicaid Services has proposed requiring health plans to handle many drug prior authorizations through electronic application programming interfaces instead of fax, phone, and portal forms. (federalregister.gov) The 511-page proposed rule, published in the Federal Register on April 14, 2026, would apply to Medicare Advantage organizations, Medicaid managed care plans, Children’s Health Insurance Program managed care entities, and qualified health plan issuers on the federally facilitated exchanges. (federalregister.gov) Prior authorization is the insurer’s advance approval process before a drug is covered, and the proposal would extend to drugs many of the electronic workflow rules that CMS finalized in 2024 for non-drug items and services. (cms.gov) CMS said the proposal would require impacted payers to support electronic prior authorization for drugs, send decision information through a Prior Authorization application programming interface, and report their application programming interface endpoints and related information to the agency. (cms.gov) The agency also proposed new timing rules: no later than 24 hours for urgent drug prior-authorization requests and 72 hours for standard requests. CMS said plans would also have to disclose denial reasons and report data on denials, appeals, and prior-authorization use. (cms.gov) The technical backbone is the same interoperability push that has been rolling through federal health programs since 2020: standardized data pipes, usually built on Fast Healthcare Interoperability Resources, so a prescriber’s software can ask a plan what it needs and receive an answer in a machine-readable format. (cms.gov) (healthit.gov) That matters because CMS left drugs out of the 2024 final rule after saying drug prior authorization used different standards and workflows than medical services. This proposal is the agency’s attempt to pull pharmacy benefit decisions into the same electronic framework. (federalregister.gov 1) (federalregister.gov 2) The Office of the National Coordinator for Health Information Technology has already moved the software side of that work. Its HTI-4 final rule, issued on July 31, 2025, added certification criteria for electronic prescribing, real-time prescription benefit tools, and electronic prior authorization in certified health information technology. (healthit.gov) CMS is also asking plans to submit application programming interface usage metrics so the agency can measure whether the electronic tools are actually being used, not just technically offered. The proposal says those reports would cover the Patient Access, Provider Access, Payer-to-Payer, Provider Directory, and Prior Authorization interfaces. (federalregister.gov) The rule is still a proposal, and CMS is taking public comments before deciding what to finalize. For now, the agency has put drug prior authorization on the same modernization track as the rest of the prior-authorization system. (cms.gov)
