CMS Proposes Faster, More Transparent Drug Prior Authorization Rules

Federal regulators are moving to end the frustrating waiting game that delays patients’ access to medications, proposing sweeping new rules that would force insurers to approve or deny drug requests within hours instead of weeks, according to a Centers for Medicare & Medicaid Services (CMS) news release.¹

“Today’s prior authorization process is still fragmented, manual, and inconsistent across payers,” Lathe Bigler, senior vice president of business strategy at Buzz Health, told Drug Topics. “CMS is proposing a shift toward standardization and digitization. Electronic prior authorization becomes the expectation, with defined timelines of 24 hours for expedited requests and 72 hours for standard requests.”

CMS has unveiled the 2026 Interoperability Standards and Prior Authorization for Drugs proposed rule, signaling a massive shift in how medications are approved and dispensed.^1,2

READ MORE: Study Shows Prior Authorization Did Not Improve Long-Term Treatment Retention of Buprenorphine

This move aims to modernize an antiquated system that currently forces pharmacists and clinicians into manual, fragmented workflows. By extending previous mandates to prescription drugs, CMS proposes that impacted payers—including Medicare Advantage and Medicaid plans—adopt application programming interfaces to support electronic prior authorization by October 1, 2027.

For pharmacy professionals, a significant change lies in the requirement for payers to support specific National Council for Prescription Drug Programs (NCPDP) standards, including SCRIPT, Formulary & Benefit, and Real-Time Prescription Benefit. These standards will allow providers to query formulary information and exchange authorization requests in real-time, effectively pulling the process upstream into the initial prescribing moment.¹

“If you strip it down, the biggest issue is not prior authorization itself, but how inefficiently it is executed. Today, providers, pharmacies, and payers operate in disconnected systems that do not always communicate,” continued Bigler. “Clinicians often do not know a drug requires prior authorization until it reaches the pharmacy, and the process is still heavily manual—relying on forms, faxes, and portals—which drives significant administrative costs and forces providers to dedicate staff just to manage the process.”

The American Medical Association reports that the volume of prior authorizations continues to grow, often acting as a barrier that places an invisible third person in the exam room. A recent study highlighted that this process consumes roughly $35 billion in annual health care administrative spending, with registered nurses alone spending time equivalent to 100,000 full-time roles on these tasks.^3,4

By shortening decision timeframes—proposing a 24-hour window for expedited requests and 72 hours for standard ones—CMS intends to mitigate these delays. Furthermore, the rule would require payers to provide specific reasons for denials, giving pharmacists and providers the data they need to appeal or resubmit effectively.¹

As the industry moves toward these Health Level Seven Fast Healthcare Interoperability Resources standards, the integration of technology like artificial intelligence (AI) is becoming a focal point.^1,2,4 While 65% of payers plan to incorporate AI into the process soon, providers remain more hesitant due to budget constraints and a lack of trust in automated tools, according to Health Affairs Scholar.⁴

Robust digital infrastructure is essential, yet technical hurdles remain. For instance, even the daily reality of browser verification and digital checkpoints, such as those managed by security services, underscores the underlying security and interoperability challenges that must be managed to ensure a seamless flow of sensitive patient information across secure connections.²

“At a high level, this is not just a policy change—it is an infrastructure change,” Bigler told us. “Prior authorization has historically been a disconnected, manual process that sits outside the prescribing workflow.”

These reforms are a fundamental transition to a digital-first health care ecosystem. By making prior authorization more transparent through public reporting of approval rates and turnaround times, CMS is introducing a level of accountability that has been historically missing.¹ For the pharmacist, this means fewer surprises at the point of sale and a more reliable, expeditious path for patients to access the therapies they need.

The proposed rule remains open for public comment until June 15, 2026, allowing stakeholders to shape the final version of these critical standards.^1,2

“CMS is now pushing the industry to digitize, standardize, and surface prior authorization earlier in the clinical decision-making process,” concluded Bigler. “The real opportunity is not just faster approvals; it is eliminating prior authorization surprises altogether by bringing coverage, cost, and authorization into the moment of prescribing.”

READ MORE: Pharmacy Leaders Gather to Improve Electronic Prior Authorization

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REFERENCES

1. 2026 CMS interoperability standards and prior authorization for drugs proposed rule. Centers for Medicare & Medicaid Services. April 10, 2026. Accessed April 22, 2026. https://www.cms.gov/newsroom/fact-sheets/2026-cms-interoperability-standards-prior-authorization-drugs-proposed-rule

2. 2026 CMS interoperability standards and prior authorization for drugs proposed rule (CMS-0062-P). Centers for Medicare & Medicaid Services. April 20, 2026. Accessed April 22, 2026. https://www.cms.gov/priorities/burden-reduction/overview/interoperability/policies-regulations/cms-interoperability-standards-prior-authorization-drugs-proposed-rule-cms-0062-p

3. Robeznieks A. As prior authorization burden grows, so does momentum for change. American Medical Association. February 20, 2025. Accessed April 22, 2026. https://www.ama-assn.org/practice-management/prior-authorization/prior-authorization-burden-grows-so-does-momentum-change

4. Sahni NR, Istvan B, Stafford C, et al. Perceptions of prior authorization burden and solutions. Health Aff Sch. 2024 Aug 6;2(9):qxae096. doi: 10.1093/haschl/qxae096.