New Prior Authorization Proposals: Implications for Prescription Drug Access

Why It Matters

The changes could lower administrative burdens, accelerate patient access to medicines, and create transparent data that reshapes insurer‑provider dynamics.

Key Takeaways

• CMS proposes extending prior‑auth time limits to prescription drugs.
• New rule aims to cut administrative costs and speed patient treatment.
• Electronic prior authorizations and APIs are mandated to replace fax.
• AI tools could streamline reviews but may raise system costs.
• Transparency metrics will require payers to publicly report PA data.

Summary

The podcast discusses CMS’s latest proposal to extend prior‑authorization deadlines to prescription drugs, building on a 2024 rule that applied only to surgeries and services.

The rule would set a one‑week response window for standard requests and three days for expedited ones, mirroring existing timelines for Medicare Advantage and Medicaid. Blue Cross Blue Shield recently reported an 11% drop in prior‑auth volume, and the Health Affairs Insider report estimates prior‑auth costs at $35 billion annually.

Guest Michael Gerber emphasizes that reducing paperwork saves practices money and speeds patient care, while also warning that AI‑driven automation could create a “payer‑bot vs. provider‑bot” arms race and increase transaction costs, as highlighted by a recent Peterson Institute study.

If finalized, the proposal mandates electronic prior authorizations via APIs and requires public reporting of approval, denial, and appeal metrics, potentially reshaping insurer workflows, prompting state‑level regulatory patches, and offering new data for research on cost and outcomes.

Original Description

Health Affairs Publishing's Jeff Byers welcomes Senior Editor Michael Gerber back to the pod to discuss recent federal action on prior authorization, including CMS’s proposal to expand response-time requirements to prescription drugs. The conversation also covers insurer efforts to reduce prior auth volume, the promise of AI and prior authorization, and what increased transparency could reveal about costs.

To learn more, check out our recent Insider trend report on the current prior authorization landscape ( https://www.healthaffairs.org/content/briefs/current-prior-authorization-landscape?utm_medium=podcast&utm_source=this+week&utm_campaign=insidermarketing&utm_content=reportspecific ). And if you haven't already, join Insider today ( https://www.healthaffairs.org/subscribe/individual?utm_medium=podcast&utm_source=this+week&utm_campaign=insidermarketing&utm_content=eventspecific ) to get access to exclusive events, newsletters, cheat sheets, and reports.

Related Links:

* CMS proposes new deadlines for prior authorizations for drugs ( https://www.healthcaredive.com/news/cms-proposes-drug-prior-authorizations-electronic-deadlines/817287/ ) (Healthcare Dive)

* 2026 CMS Interoperability Standards and Prior Authorization for Drugs Proposed Rule ( https://www.cms.gov/newsroom/fact-sheets/2026-cms-interoperability-standards-prior-authorization-drugs-proposed-rule ) (CMS)

* A Rule by the Centers for Medicare & Medicaid Services on 02/08/2024 ( https://www.federalregister.gov/documents/2024/02/08/2024-00895/medicare-and-medicaid-programs-patient-protection-and-affordable-care-act-advancing-interoperability ) (Federal Register)

* Health Plans Reduce Prior Authorization, Support Continuity of Care and Enhanced Consumer Communications ( https://www.bcbs.com/about-us/association-news/health-plans-reduce-prior-authorization-continuity-of-care ) (Blue Cross Blue Shield)

* AI speeds up prior auth, coding while driving higher costs for health systems: PHTI report ( https://www.fiercehealthcare.com/ai-and-machine-learning/ai-speeding-prior-authorizations-while-driving-higher-costs-health-systems ) (Fierce Healthcare)

Sign up for our free Health Affairs newsletters ( https://www.healthaffairs.org/newsletters?utm_medium=podcast&utm_source=a+health+podyssey&utm_campaign=newsletters ) to stay up to date on health policy news and analysis.

Health Affairs This Week

Episode 245

April 24, 2026

★ Episode details: https://share.transistor.fm/s/f8cd2af7

★ Additional episodes: http://www.healthaffairs.org