CMS proposed on April 10, 2026 that Medicaid and CHIP plans decide every drug prior authorization request within 24 hours, and that federal marketplace plans decide standard drug requests within 72 hours. The proposal sets October 1, 2027 as the first compliance date, and its comment period closed June 15, 2026.
The rule is CMS-0062-P, "Interoperability Standards and Prior Authorization for Drugs." It extends to drugs the electronic prior authorization requirements that CMS set for medical items and services in its 2024 final rule, CMS-0057-F. Decision speed is the part a practice can measure from its own request logs.
The proposed decision deadlines
CMS's April 10, 2026 fact sheet gives different clocks for different payers. State Medicaid fee-for-service programs, Medicaid managed care plans and CHIP managed care entities would decide all drug requests no later than 24 hours after receipt, matching the timeframe already used for covered outpatient drugs. Qualified Health Plan (QHP) issuers on the federally facilitated exchanges would have 72 hours for standard drug requests and 24 hours for expedited ones.
The same fact sheet restates the QHP clocks for non-drug items and services: seven calendar days for standard requests and 72 hours for expedited requests. It sets no separate drug timeframe for Medicare Advantage organizations. CMS proposes compliance dates beginning October 1, 2027 for all of the decision timeframes.
| Payer and request type | Proposed decision deadline |
|---|---|
| Medicaid and CHIP, all drug requests | 24 hours |
| QHP issuers, standard drug request | 72 hours |
| QHP issuers, expedited drug request | 24 hours |
| QHP issuers, standard non-drug request | 7 calendar days |
| QHP issuers, expedited non-drug request | 72 hours |
Source: CMS fact sheet, "2026 CMS Interoperability Standards and Prior Authorization for Drugs Proposed Rule," April 10, 2026.
Who the rule covers and when each date falls
The fact sheet lists seven payer types. They are Medicare Advantage organizations, state Medicaid fee-for-service programs, state CHIP fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, QHP issuers on the federally facilitated exchanges, and, new in this proposal, small group QHP issuers on the federal Small Business Health Options Program (SHOP).
The timeline has several clocks that start at different points:
- Electronic prior authorization for drugs, the decision deadlines and denial-reason communication: October 1, 2027.
- The HIPAA FHIR standard: 24 months after the final rule takes effect for covered entities, 36 months for small health plans.
- API endpoint reporting: 60 days after the final rule takes effect for existing payers, with updates within one week of any change.
- Drug prior authorization metrics and API usage metrics: reporting begins in 2028, using 2027 data.
The law firm Crowell reported that SHOP issuers would comply with plan years beginning January 1, 2028. CMS also proposes that its current health IT standards expire on January 1, 2028, and it lists seven implementation guides, among them the HL7 FHIR Da Vinci Prior Authorization Support guide, to be required by October 1, 2027.
What the proposal leaves out
Drugs covered under a pharmacy benefit follow a different technical path than drugs covered under a medical benefit. The pharmacy benefit uses three National Council for Prescription Drug Programs (NCPDP) standards: SCRIPT, Formulary and Benefit, and Real-Time Prescription Benefit. Medical-benefit drugs use the same FHIR-based prior authorization API as non-drug services, according to CMS.
Crowell's client alert states that Medicare Part D drugs are exempt from the new metrics reporting for Medicare Advantage prescription drug plans. Retail pharmacy transactions stay under existing pharmacy industry standards.
For denied drug requests, the patient and provider APIs would carry six data points: authorization status, approval or denial date, authorization end date, approved drug and dosage, the specific denial reason, and related documentation. The payer-to-payer API carries the same fields except for denied requests. The fact sheet gives no cost or savings estimate. It also attaches five standalone requests for information, including step therapy and laboratory tests, which carry no deadlines.
What electronic prior authorization looks like today
Drug Topics reported on April 23, 2026 that prior authorization accounts for $35 billion in annual health care administrative spending, and that registered nurse time spent on it adds up to 100,000 full-time equivalent roles each year. Those totals frame the proposal, but they come from the outlet's coverage and not from a practice-level study.
Surescripts published network data in May 2026 that shows what electronic requests do in practice. HIT Consultant reported on May 20, 2026 that Surescripts has 68,000 active prescribers enabled, a 50% increase since December 2025, along with 42 health systems. Another 119,000 clinicians are scheduled to go live later in 2026. The median approval time for authorized requests is 18 seconds.
In the same report, Surescripts says its automation lowered the denial rate for missing information by 11% and cut medical appeals by 17%. It supports 104 medications, up from 40 in 2024, and 34% of requests for in-scope therapies receive an automated approval. These are the vendor's own figures, measured on its own network.
The physician-side baseline
The American Medical Association's 2026 prior authorization physician survey, released May 13, 2026, gives the clinical-side baseline. As the American Hospital Association summarized it, 95% of physicians reported delays in access to care and 92% reported a negative effect on patient outcomes. Another 88% reported higher overall resource use, and 26% reported a serious adverse event linked to prior authorization.
The AMA survey also found that 32% of physicians say prior authorization requests are often or always denied. A practice that logs request date, decision date and outcome for drug requests before October 1, 2027 will have its own figures to hold against the 24-hour and 72-hour deadlines.
CMS has not issued a final rule as of the sources reviewed here, and the dates above apply to the proposal only.
Sources
- CMS, 2026 CMS Interoperability Standards and Prior Authorization for Drugs Proposed Rule fact sheet, April 10, 2026
- Crowell, CMS Seeks to Expand Interoperability Requirements to Drug Pre-Authorization (FAQ), 2026
- Drug Topics, CMS proposes faster, more transparent drug prior authorization rules, April 23, 2026
- Frier Levitt, CMS Electronic Prior Authorization for Drugs Proposed Rule, April 27, 2026
- HIT Consultant, Surescripts expands prior authorization automation data, May 20, 2026
- American Hospital Association, AMA survey shows physicians, patients continue to be heavily burdened by prior authorization, May 14, 2026
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