New CMS Rule Aims to Streamline Prior Authorization for Drugs

The Centers for Medicare & Medicaid Services (CMS) has introduced a proposed rule for the 2026 CMS Interoperability Standards and Prior Authorization for Drugs. This initiative aims to mitigate AI-driven prior authorization delays and enhance transparency within federal health insurance programs by implementing electronic prior authorization (ePA) protocols for prescription drugs. By expediting the federal response, the rule seeks to ensure timely access to essential medications, minimizing administrative holdups.

Starting October 1, 2027, the rule mandates health plans deploy a Prior Authorization Application Programming Interface (API) to facilitate ePA for prescription medications. This aligns API standards for drug authorizations with those for non-drug healthcare services, a change endorsed by the Association for Clinical Oncology (ASCO). Proposed decision timeframes set a maximum of 24 hours for urgent requests and 72 hours for standard ones, streamlining processes across regulatory compliance requirements.

ASCO, a vocal advocate for reforms in prior authorization to prevent patient harm, revealed significant concerns through a survey. Results indicated that prior authorization practices resulted in treatment delays (96%), adverse health impacts like disease progression (80%), and fatalities (36%). Lynn M. Schuchter, MD, FASCO, Chair of ASCO's Board for 2025-2026, emphasized that ePA support and set timelines would significantly enhance patient care accessibility, especially for cancer patients, where treatment delays are critical.

ASCO expressed gratitude to CMS for heeding stakeholder calls to include prescription drugs in prior authorization reforms. They stressed that such authorizations escalate administrative burdens, hindering patient care and access to necessary treatments. ASCO plans to contribute feedback from the cancer community during the June 2026 comment period and will continue to advocate for reforms improving patient access to cancer care.