Interoperability Standards and Prior Authorization for Drugs Proposed Rule Summary

On April 14, 2026, CMS, along with the Office of the National Coordinator for Health Information Technology of the Department of Health and Human Services, published in the Federal Register (91 FR 19890) a proposed rule to require impacted payers to do the following:

• Make available electronic prior authorization for drugs,
• Apply many existing interoperability requirements for the prior authorization of non-drug items and services to prior authorizations for drugs,
• Report their application programming interfaces endpoints and related information for the Patient Access, Provider Directory, Provider Access, Payer-to-Payer, and Prior Authorization APIs to CMS,
• Apply certain Health Level Seven Fast Healthcare Interoperability Resources implementation guides that are currently recommended

Impacted payers are the following:

• Medicare Advantage organizations,
• State Medicaid fee-for-service programs,
• State Children’s Health Insurance Program FFS programs,
• Medicaid managed care plans,
• CHIP managed care entities, and
• Qualified Health Plan issuers on the Federally-facilitated Exchanges, including issuers that offer small group market QHPs on the Federally-facilitated Small Business Health Options Program Exchanges.

Comments are due by June 15, 2026.