Mid-Year Check-In: Has Prior Auth Reform Delivered?

Pharmaceutical Commerce continues its H1 Review/H2 Outlook series, revisiting the predictions and priorities industry voices shared earlier this year. This installment features Amy Niles, chief mission officer at the Patient Advocate Foundation, in the first of a three-part video interview.

Niles told Pharmaceutical Commerce that prior authorization reform has made real, if incremental, progress since she shared her 2026 outlook in February. A CMS final rule that took effect Jan. 1 covers prior authorization for non-drug items and services, such as certain procedures and durable medical equipment, and shortened decision timelines for that category: standard requests must now be decided within seven calendar days and urgent requests within 72 hours, down from a previous 14-day window.¹ The rule also requires payers to issue clear reasons for denials and to publicly report approval, denial and appeal metrics, adding transparency Niles said has been missing from the system.

CMS also launched a five-year pilot called the Wasteful and Inappropriate Service Reduction Model, which pairs artificial intelligence with human reviewers to make prior authorization decisions for traditional Medicare in six states: Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington.² A separate proposed rule, issued in April, would extend electronic prior authorization to drugs covered under Medicare Part B; if finalized, it would take effect Oct. 1, 2027.³ The Improving Seniors' Timely Access to Care Act, which would codify similar reforms for Medicare Advantage, remains stalled despite bipartisan support, she says.

On the Medicare Prescription Payment Plan, which lets beneficiaries spread drug costs across the year, Niles pointed to research her organization commissioned with IQVIA across five high-cost therapeutic areas. Only 7% of eligible beneficiaries opted in during 2025, but those who did saw therapy abandonment fall to 17%, compared with 41% for those who didn't enroll, she notes. A separate survey of more than 4,200 Medicare beneficiaries found only half had heard of the program, underscoring a persistent awareness gap.

References

1. Centers for Medicare & Medicaid Services, "CMS Interoperability and Prior Authorization Final Rule CMS-0057-F," fact sheet, Jan. 17, 2024, https://www.cms.gov/newsroom/fact-sheets/cms-interoperability-prior-authorization-final-rule-cms-0057-f.
2. Centers for Medicare & Medicaid Services, "WISeR (Wasteful and Inappropriate Service Reduction) Model," CMS.gov, accessed July 22, 2026, https://www.cms.gov/priorities/innovation/innovation-models/wiser.
3. Centers for Medicare & Medicaid Services, "2026 CMS Interoperability Standards and Prior Authorization for Drugs Proposed Rule," fact sheet, April 10, 2026, https://www.cms.gov/newsroom/fact-sheets/2026-cms-interoperability-standards-prior-authorization-drugs-proposed-rule.