CMS-0062 is coming for drugs. Is anyone ready?

Why this matters: The proposed CMS-0062 rule would extend electronic prior authorization (PA) requirements to drugs, with a proposed compliance date of October 1, 2027. In this blog:

• What the proposed rule would require of health plans
• Three signs a plan is ready for drug PA changes
• Why the work starts before the rule is final

Many health plans are still working through the requirements of CMS-0057. The 2024 final rule introduced new prior authorization APIs, faster decision timelines, and public reporting obligations, but notably left drugs out of scope.

That gap is now being addressed. In April, CMS released a proposed rule–CMS-0062-P–that brings drugs back into the picture. Formally titled the 2026 CMS Interoperability Standards and Prior Authorization for Drugs proposed rule, would extend electronic PA to drugs covered under both the medical and pharmacy benefits.

The rule has not yet been finalized, and its timeline may shift. However, for plans with infrastructure already in place, now is the time to start planning for the next phase of requirements.

What the proposed rule would require

CMS-0062 follows the same blueprint as CMS-0057, with drug-specific standards and tighter clocks layered on top. As proposed, it applies to Medicare Advantage organizations, Medicaid and Children's Health Insurance Program (CHIP) programs and managed care plans, and qualified health plan (QHP) issuers on federally facilitated exchanges, and it would add small group QHP issuers on the federally facilitated Small Business Health Options Program.

Two tracks, split by benefit. Drugs covered under the medical benefit would run through the same FHIR-based Prior Authorization API that plans are building for CMS-0057. Drugs covered under the pharmacy benefit would use National Council for Prescription Drug Programs (NCPDP) standards: SCRIPT for PA requests and decisions, plus Formulary & Benefit and Real-Time Prescription Benefit. Medicare Part D sponsors already support these; Medicaid, CHIP, and exchange plans would join them.

Faster drug decisions. Proposed timeframes are tighter and aligned across programs:

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Specific denial reasons. Plans would need to give clinicians a specific reason for any drug PA denial, matching what CMS-0057 already requires for medical services.

Public drug metrics. Plans would report drug PA metrics on their public websites each year, starting in 2028 with 2027 data.

The proposed rule also reaches past drugs and into the medical services scope of CMS-0057. It would make the HL7 Da Vinci implementation guides a requirement, rather than a recommendation, expand API usage reporting to include the Prior Authorization API, and require health plans to report their FHIR endpoints to CMS, instead of simply attesting that their APIs are available. 

What readiness actually looks like

Readiness for CMS-0062 shows up in three places, and only one of them is technical.

1. You know what carries over and what's new. For drugs under the medical benefit, CMS-0062 would use the same Prior Authorization API plans built for CMS-0057, so that work would need to expand to cover drugs. On the pharmacy side, NCPDP standards are already well established, though Medicaid, CHIP, and exchange plans would be required to support them for the first time. Ready plans have scoped both.

2. Your clinical team can keep pace with the clock. Electronic intake gets a request in the door faster. It doesn't shorten the clinical review behind it. A 24-hour decision window on a complex specialty drug still needs a clinician to find the right documentation, check it against plan criteria, and decide. Plans need a way to move routine requests quickly, so clinicians can spend their time on the cases that need judgment.

3. Your decisions hold up in public. Specific denial reasons and public drug metrics make decision quality visible to clinicians, members, and regulators. That puts a premium on consistent criteria and well-documented reviews as much as speed.

Why readiness is a clinical question

Details and deadlines may shift before the final rule lands, but the direction is clear. Drug PA is moving onto the same electronic infrastructure as PA for medical services, on a tighter timeline and under more public scrutiny. Plans that use this window to rethink how drug decisions get made, while building the infrastructure to support them, will be better positioned when the rule is final.

At Cohere Health, we're helping health plans get ahead of CMS-0062–building on the foundation that CMS-0057 already put in place.

Still sorting out where CMS-0057 leaves your team? See how Cohere Health's PA APIs support CMS-0057, and subscribe to the Cohere Health newsletter for what comes next.