LUGPA Policy Update: CMS Proposes Major Reforms to Prior Authorization for Drugs

April 2026

At-a-Glance Essentials

What’s Changing
CMS would require faster prior authorization decisions (24 hours for urgent requests and 72 hours for standard requests), expand electronic prior authorization to prescription drugs, and mandate public reporting of key metrics to improve transparency and accountability.

Why It Matters
The proposal aims to reduce treatment delays, ease administrative burden, and hold payers accountable for prior authorization practices.

Key Dates
Proposed rule released April 2026; implementation expected beginning in 2027.

Overview

The Centers for Medicare & Medicaid Services (CMS) has issued a proposed rule titled Interoperability Standards and Prior Authorization for Drugs to modernize prior authorization (PA) processes for medications.

Building on its 2024 interoperability rule for non-drug services, CMS is extending similar requirements to prescription drugs across Medicare Advantage, Medicaid, CHIP, and marketplace plans. The proposal is intended to eliminate delays, replace outdated manual processes, and create a more standardized and transparent prior authorization system.

Key Provisions

The rule establishes clear timelines for prior authorization decisions, requiring payers to respond within 24 hours for urgent requests and 72 hours for standard requests. It also expands electronic prior authorization requirements to drugs, moving away from fax-based and manual workflows toward real-time digital systems.

To improve accountability, CMS would require plans to publicly report data on prior authorization performance, including denial rates, appeals, and decision timeframes. The rule also adopts modern interoperability standards using FHIR-based APIs, enabling more seamless data exchange and faster submission of clinical documentation.

Additional provisions include updates to health IT standards, expanded interoperability requirements across additional plan types, and new oversight mechanisms under the Open Payments program. CMS is also seeking stakeholder input on related issues, including step therapy, laboratory testing, and durable medical equipment.

Most provisions would take effect beginning in 2027.

Why This Matters for Independent Urology Practices

Prior authorization remains one of the most significant administrative burdens for independent urology practices. Many commonly prescribed therapies, particularly in oncology, men’s health, and chronic bladder conditions, require prior authorization, often resulting in delays that disrupt care and increase staff workload.

This proposal directly targets those challenges by establishing enforceable timelines, digitizing the process, and increasing visibility into payer behavior. Together, these changes have the potential to reduce treatment delays, improve patient outcomes, and enable practices to shift resources away from administrative tasks and back toward clinical care.

Impact on LUGPA Members

For LUGPA members, the proposed reforms could meaningfully improve both clinical and operational efficiency. Faster decision timelines should help ensure more timely initiation of therapies, particularly for patients with complex or time-sensitive conditions.

The transition to electronic prior authorization is expected to reduce the administrative burden associated with manual submissions and repeated follow-ups, which remain major drivers of practice overhead and staff burnout. At the same time, increased transparency into payer decision-making will provide practices with better data to identify problematic patterns and support advocacy efforts.

Aligning prior authorization requirements for drugs with existing rules for medical services also creates greater consistency across workflows, simplifying operations for practices managing a wide range of treatments.

LUGPA Perspective

LUGPA strongly supports efforts to reduce prior authorization burden, improve transparency, and ensure timely patient access to medically necessary treatments. This proposal reflects many of LUGPA’s longstanding advocacy priorities.

We will continue to review the rule and engage with CMS, particularly regarding opportunities to streamline step therapy further and address ongoing barriers to drug access. LUGPA will keep members informed as the rulemaking process advances and provide opportunities for engagement.

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