CMS proposes prior authorization overhaul

CMS on April 14, 2026 formally published a proposed rule that would push prior authorization for prescription drugs further into a standardized, electronic workflow across several federal health programs. The proposal, docketed as CMS-0062-P, builds on earlier interoperability rules but shifts the focus to drugs rather than the non-drug items and services addressed in a 2024 final rule. (federalregister.gov) CMS said the aim is a faster, more transparent and more reliable process for patients, clinicians and payers. The rule is still only a proposal, and the public comment period closed on June 15, 2026. (cms.gov) ### Which plans and programs would this rule actually touch? CMS said the proposal applies to Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, and Qualified Health Plan issuers on the federally facilitated exchanges. (federalregister.gov) The agency also proposed adding small-group market exchange issuers on the federally facilitated Small Business Health Options Program, or FF-SHOP, to the list of affected payers. The Federal Register notice published April 14, 2026 lists the rule as covering Medicare Advantage organizations, Medicaid managed care plans, state Medicaid agencies, CHIP agencies and managed care entities, and issuers of qualified health plans on federally facilitated exchanges. Penn LDI said the proposal reaches “a range of federally run and facilitated healthcare programs,” extending prior authorization changes into the prescription-drug setting. (federalregister.gov) ### What is CMS trying to change in drug prior authorization? CMS said the 2026 proposal would extend many of the 2024 prior authorization requirements to drugs. That includes support for electronic prior authorization, shorter decision timeframes aligned across CMS programs, and added transparency around how drug prior authorization decisions are made and reported. (cms.gov) HHS also proposed adopting certain HL7 FHIR standards and implementation specifications for prior authorization transactions under HIPAA administrative simplification rules. CMS said those standards would apply to HIPAA covered entities that electronically exchange prior authorization information for items and services. ### Why is this different from the 2024 rule? The 2024 final rule focused on non-drug items and services, while the 2026 proposal extends many of those same process requirements to drugs, CMS said. (federalregister.gov) Penn LDI said the new rule also separates two settings that often get blurred together in policy debates: drugs covered under a medical benefit and drugs covered under a pharmacy benefit. Penn LDI said the proposal is aimed at prior authorization procedures and communications rather than broad new substantive limits on utilization management. (cms.gov) In its summary, the group said the rule would establish and require electronic prior authorization, set coverage-decision deadlines, and promote transparency through annual reporting metrics. ### What would change for doctors, pharmacies and patients? (cms.gov) CMS said electronic prior authorization would let providers determine whether prior authorization is required, use electronic forms to submit requests, and exchange requests and decisions with payers through standardized interfaces. The agency framed that as part of a broader interoperability effort that began with its 2020 patient access rule and its 2024 prior authorization rule. (cms.gov) Penn LDI said the likely operational effect would be on the back-and-forth that now slows prescribing and coverage decisions, especially in outpatient care. The authors said the proposal is about how coverage decisions are reviewed and communicated, with implications for cost, quality and access if the rule is finalized. (ldi.upenn.edu) ### What happens next in the rulemaking process? The Federal Register notice said comments were due by June 15, 2026, to be assured consideration. CMS has published a comment guide for CMS-0062-P and a summary of proposed provisions, but it has not yet issued a final rule. CMS’s next formal step would be a final rule or other rulemaking action under docket CMS-0062-P. (ldi.upenn.edu) Until then, the April 2026 proposal remains the operative document for providers, plans and policy groups tracking changes to prescription-drug prior authorization. (federalregister.gov)