Overview
- CMS proposed a rule to speed insurer pre-approval for prescription drugs, requiring answers within 24 hours for urgent requests and 72 hours for standard ones.
- The proposal would cover Medicare Advantage plans, state Medicaid and CHIP programs, and Affordable Care Act plans on federal marketplaces, including small-group issuers on FF-SHOP.
- Plans would need to publicly post denial and appeal rates, show decision timelines, and give specific reasons when drug coverage is denied.
- Affected payers would have to support electronic prior authorization APIs that include drug coverage criteria, and CMS proposed HL7 FHIR standards for these transactions across HIPAA-covered entities.
- If finalized, the changes would start on October 1, 2027, with comments now open as payers report an 11% drop in prior authorizations and physicians cite widespread care delays.