For a patient waiting on treatment, prior authorization is rarely just paperwork. It’s the days or weeks between a doctor’s decision and the care that decision was supposed to deliver—time a serious illness doesn’t always give back.

That’s why we submitted a public comment on the 2026 CMS Interoperability Standards and Prior Authorization for Drugs Proposed Rule (CMS-0062-P)—the federal government’s most significant attempt yet to fix how prior authorization works for medications. Below is what we told the Centers for Medicare & Medicaid Services, and why it matters for patients and families.

The rule, in plain terms

Prior authorization is the process that requires your doctor to get a health plan’s approval before a prescribed medication, test, or service will be covered. It’s meant to manage costs—but for patients it too often means delay, denial, or simply giving up on care a clinician already said was needed.

Published in the Federal Register on April 14, 2026, the proposed rule would—for the first time—extend electronic prior authorization to drugs across both the medical and pharmacy benefit, set shorter decision timelines, and require greater transparency. It also asks the public specific questions about step therapy and about prior authorization for laboratory testing. We responded to all of it.

Why prior authorization matters for patients

The need is written in CMS’s own data. In 2024, Medicare Advantage insurers made nearly 53 million prior authorization determinations and denied 4.1 million of them. Only about 1 in 9 denials were appealed—yet more than 80% of those appeals were overturned. (KFF analysis of CMS data). In other words, most patients never challenge a denial—and when they do, the original “no” is reversed far more often than not.

Physicians describe the same picture. In the American Medical Association’s most recent national survey, 95% said prior authorization delays necessary care, 79% reported that patients abandon treatment because of it, and more than one in four said it had caused a serious adverse event for a patient in their care—including hospitalization, permanent impairment, or death (AMA 2025 Prior Authorization Physician Survey).

What we asked CMS to change

We support the direction of the rule, and we asked CMS to make it work for the people living inside the system. Our comment recommended that the final rule:

• Make electronic prior authorization patient-visible — require it across both the medical and pharmacy benefit, and let patients, not only providers, see the status and outcome of a request about their own care.
• Pair speed with accountability — require 24-hour decisions across markets, with CMS oversight so a faster clock doesn’t become an automatic “no.”
• Require honest denials — every denial, including the first, should come with a plain-language reason, delivered to the patient at the same time as the provider. You can’t appeal what you were never told.
• Publish the numbers patients can use — require public, plan-level reporting (including Part D), broken out by brand vs. generic and by therapeutic area, with initial denials and step therapy included.
• Protect patients from “fail first” — don’t let Medicare Advantage plans expand step therapy; honor steps a patient has already completed when they switch plans; and keep step therapy transparent rather than buried inside prior authorization.
• End timing-based denials of lab tests — stop denying a test because authorization was still pending the day blood was drawn, accept the test requisition form as valid documentation, and examine the role of laboratory benefit managers.

The costs that don’t show up in a spreadsheet

We also asked CMS to weigh what a budget table can’t. The burdens of prior authorization don’t fall evenly. They land hardest on the sickest patients—those in cancer treatment, those with rare and complex conditions—and on working families who must take unpaid time off for a repeat blood draw or an extra visit. The exhaustion of fighting your own insurer while you’re sick is a real cost, even if no one assigns it a dollar figure.

What happens next—and how patients can advocate

CMS now reviews the public comments and must respond to significant, relevant ones in any final rule. If finalized, most changes would take effect October 1, 2027. The comment window is closed, but the conversation isn’t.

Patients don’t have to wait for a rule to advocate for themselves. If your care is delayed or denied, ask your plan for the specific reason in writing, ask your care team to back your appeal, and remember the number above: appeals are overturned far more often than most people expect. Our free Appeal Game Plan — a one-page checklist of the steps, your plan's deadlines, and where to get free help — walks you through exactly what to do, and our Learning Center explains your rights in moments like these.

Frequently asked questions

What is prior authorization?

Prior authorization is a process that requires a patient’s doctor to get approval from a health plan before a prescribed medication, test, or service will be covered. It’s intended to control costs, but it frequently delays or blocks care a clinician has already determined a patient needs.

What is CMS-0062-P?

CMS-0062-P is the 2026 CMS Interoperability Standards and Prior Authorization for Drugs Proposed Rule, published April 14, 2026 (Docket No. CMS-2026-1255). It would require electronic prior authorization for drugs across the medical and pharmacy benefit, set shorter decision timelines, increase transparency, and gather input on step therapy and on prior authorization for laboratory testing.

When were comments on the rule due?

Public comments were due June 15, 2026, submitted through Regulations.gov under Docket No. CMS-2026-1255.

What did Patients Rising ask CMS to change?

Six things: patient-visible electronic prior authorization across the medical and pharmacy benefit; 24-hour decisions paired with oversight against automatic denials; plain-language denial explanations to patients and providers for every denial; public, plan-level reporting including Part D; step-therapy protections; and an end to timing-based lab-test denials, with the test requisition form accepted as valid documentation.

How can a patient handle a prior authorization denial?

Appeal it—and don’t be discouraged. More than 80% of appealed Medicare Advantage denials are overturned. Ask the plan for the specific reason in writing, ask your care team to support the appeal, and use patient-education resources such as the Patients Rising Learning Center to understand the steps.

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