Impacted: Medicaid Fee-for-Service, Medicaid managed care, the Children's Health Insurance Program (CHIP), ACA exchange-based Qualified Health Plans with some requirements applying to existing requirements already applicable to Medicare Advantage

 

What you need to know

As a follow up to our previous communication in April 2026, Prime submitted a comment letter on June 15, 2026, in response to the Centers for Medicare & Medicaid Services (CMS) proposed rule — (91 Fed. Reg. 19890) to modernize prior authorization (PA) processes for prescription drugs for several federally regulated lines of business.

The full text of our comments can be accessed here.

Prime supports CMS’ overall policy direction toward improving interoperability, transparency and improving the PA experience for providers and patients. We remain committed to efficiency and patient-first pharmacy care. In keeping with that promise, we’ve submitted comments to support the agency’s goals while recommending operational refinements to help ensure the final framework is workable across payer categories. 

For awareness only — there is no required client action.

Overview

On April 10, 2026, CMS issued the Interoperability Standards and Prior Authorization for Drugs proposed rule — building on the CMS 2024 final rule — which focused on PA modernization for non-drug items and services. The proposal would apply new and updated requirements across both medical-benefit and pharmacy-benefit drug PA workflows.

The proposed rule reinforces the use of established standards already in use today, including the National Council for Prescription Drug Programs (NCPDP) standards for pharmacy-benefit drugs and Fast Healthcare Interoperability Resources (FHIR^®)-based standards for medical-benefit drugs. It also proposes new turnaround time requirements for certain drugs and public requirements related to PA performance. 

CMS called for a public comment period through mid-June 2026 with a final rule expected later this year. Phased implementation would begin in October 2027, extending into 2028. 

Prime's position

We offered comments drawing from our operational experience and implementation perspective. We also consulted with the Blue Cross Blue Shield Association (BCBSA) during the drafting process to help inform our approach.

We endorsed the comments submitted by the Pharmaceutical Care Management Association (PCMA), supplementing our comments with additional input to reflect our perspective.

Summary of key themes from our comments include:

• Additional implementation time for medical-benefit drug PA under FHIR^® PA Application Programming Interface (API): We recommended that CMS extend the compliance timeline for incorporating medical-benefit drug PA into FHIR API to allow sufficient time for implementation. Based on Prime’s operational experience, this will require nine to 15 months of build effort from the date the drug PA implementation requirements are finalized.
• Standards adoption calibrated to system readiness: We supported adoption of the NCPDP standards for drug PA, formulary and benefit exchange and real-time prescription benefit workflows. We recommended that CMS provide additional implementation time where ecosystem readiness varies, particularly for non-Part D programs.
• Future consideration of avoided-PA measure for pharmacy-benefit drugs: We encouraged CMS to engage with stakeholders on development of a future “avoided PA” measure limited to pharmacy-benefit PA, which could help capture how point-of-prescribing tools and benefit transparency reduce unnecessary PA volume.
• Additional time before public reporting of drug PA metrics: We supported the transparency goals of public reporting while recommending additional time before public posting begins so impacted payers can operationalize new definitions and reporting requirements consistently.

Next steps

The proposed rule is expected to be finalized in late 2026. We stand ready to engage further with CMS and believe a collaborative approach to this rulemaking will produce a framework that delivers meaningful interoperability and administrative simplification. We will continue to monitor developments and keep you updated.  

Questions

Reach out to your Prime account team representative.