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Insight · CMS-0062-P (proposed rule)

CMS-0062-P: drug prior authorization through the API by October 1, 2027, if finalized

Short answer: CMS-0062-P would put medical-benefit drugs on the FHIR Prior Authorization API and pharmacy-benefit drugs on NCPDP standards from October 1, 2027, with a specific denial reason and 24-hour and 72-hour drug clocks for exchange plans. Proposed, not final.
Published Apr 14, 2026 · 60-day commentsMedical benefit · FHIR APIPharmacy benefit · NCPDP SCRIPTOct 1, 2027 · proposed

October 27, 20266 min readASP-RCM Solutions

Focus
Drug prior auth
Framework
CMS-0062-P
Effective date
Oct 1, 2027 proposed
Payers
6 types
Codes
FHIR · NCPDP
Length
6 min
Oct 1, 2027
Proposed compliance date for electronic prior authorization of all drugs through the Prior Authorization API and NCPDP standards [1]
24h / 72 h
Proposed drug decision notice limits for exchange QHP issuers: expedited and standard [1]
Apr 14, 2026
Federal Register publication of CMS-0062-P with a 60-day comment period (proposed, not final) [1]
6payer types
The CMS-0057-F list plus FF-SHOP small group QHP issuers [1]
What the rule proposes

One rule, two drug tracks

CMS-0057-F left drugs out of every 2027 API [2]. CMS-0062-P, released April 10, 2026, closes the gap by benefit type.

Drug benefitStandardWhat the authorization team gets
Medical benefitJ-codes, infusion, injectables
StandardFHIR Prior Authorization API, the one CMS-0057-F built for procedures [1]
AnswerRequired or not, documentation requirements, request and decision, specific denial reason
Pharmacy benefitPrescriptions
StandardNCPDP SCRIPT, Formulary and Benefit, Real-Time Prescription Benefit, as Part D sponsors run today [1]
AnswerElectronic prior authorization inside e-prescribing; ask the EHR vendor about Part D support [3]
Either benefitAll impacted payers
DateOctober 1, 2027, proposed [1] [3]
StatusNot final until a final rule publishes
Who is impacted

CMS-0062-P scope and proposed dates

PayerDrug prior authorization through API and NCPDP standardsSpecific denial reason for drugs
Medicare Advantage organizationsOct 1, 2027 proposedExisting Part B drug rules continue
State Medicaid and CHIP FFS programsOct 1, 2027 proposed; extension process proposedOct 1, 2027 proposed
Medicaid managed care plans and CHIP managed care entitiesOct 1, 2027 proposedOct 1, 2027 proposed
QHP issuers on the FFEsOct 1, 2027 proposed; exception process via QHP certificationOct 1, 2027 proposed
Small group QHP issuers on the FF-SHOPsPlan years from Jan 1, 2028 proposedSame
Decision clocks for drugs

Hours to notify the provider, drug versus non-drug

Proposed notice limits for QHP issuers on the FFEs, in hours [1]

Non-drug clocks from the 2024 rule [2]; CHIP FFS prescription drugs would also get 24 hours.

Non-drug, standard7 calendar days
168 h100%
Non-drug, expedited
72 h43%
Drug, standardproposed
72 h43%
Drug, expeditedproposed
24 h14%
Medicaid covered outpatient drugsexisting
24 h14%
04896144168 h
Non-drug standardNon-drug expeditedDrug, proposedDrug, existing Medicaid
Proposed, not finalCompliance dates, the drug clocks and the SHOP inclusion can all change in the final rule.
What else the rule adds

Five more proposals

Specific denial reason for drugs

Oct 1, 2027 proposed

  • Medicaid and CHIP FFS, managed care, QHP issuers [1]

API endpoint reporting

To CMS

  • All five API endpoints plus usage metrics [1]

Public drug metrics

From 2028

  • Drug metrics, excluding covered Part D drugs for MA-PD plans [1]

FFS extension process

Replaces small-state exemption

  • Any Medicaid or CHIP FFS program may request more time on the non-drug API, until the HIPAA standards proposals take effect [1]

Standards without fixed versions

45 CFR 170.215

  • Any unexpired adopted version; SCRIPT 2017071 expires January 1, 2028, then 2023011 [1]
On the calendar

Drug prior authorization, date by date

  1. 1
    CMS-0057-F releasedJan 17, 2024Drugs excluded [2]
  2. 2
    CMS-0062-P publishedApr 14, 202660-day comments, proposed
  3. 3
    Non-drug API requiredJan 1, 2027CMS-0057-F API live
  4. 4
    Drug prior auth electronicOct 1, 2027Proposed: API, medical; NCPDP, pharmacy
  5. 5
    SCRIPT 2017071 expiresJan 1, 2028Proposed SHOP QHP plan years; drug metrics begin
Takeaway

Drugs get their own API track nine months after procedures. The medical-versus-pharmacy flag decides the standard, the system and the date.

What to do this week

Four steps before the final rule

Add a benefit flagMedical versus pharmacy on every drug authorization; our eligibility verification workbench carries it.
List impacted payers for medical-benefit drugsInfusion, oncology, rheumatology, neurology, long-acting injectables. API route proposed for October 1, 2027; until then prior authorization automation runs J-code packets by portal, fax and EDI, in the order set by our sequencing guide; full AI suite.
Ask the EHR vendor two questionsAPI consumption for drugs; NCPDP electronic prior authorization for Part D [3].
Log request and decision times nowSo the 24-hour and 72-hour proposals can be checked against reality.
FAQ

Frequently asked questions

What is CMS-0062-P?

A proposed rule from CMS and ONC, published in the Federal Register on April 14, 2026, that would require impacted payers to support electronic prior authorization for all drugs through the Prior Authorization API (medical-benefit drugs) and NCPDP standards (pharmacy-benefit drugs) beginning October 1, 2027. It also proposes API endpoint reporting, drug prior authorization metrics from 2028 and a specific denial reason for drugs. It is proposed, not final.

Does CMS-0057-F already cover drug prior authorizations?

No. CMS-0057-F excludes drug prior authorizations from the Prior Authorization API, the decision timeframes and the denial reason requirement. CMS-0062-P is the proposal to extend those policies to drugs.

What are the proposed decision timeframes for drug prior authorization?

For QHP issuers on the federally facilitated exchanges, CMS proposes notice to the requesting provider no later than 72 hours for standard drug requests and 24 hours for expedited drug requests. Medicaid covered outpatient drugs already carry a 24-hour timeframe, and CMS proposes 24 hours for CHIP FFS prescription drugs. All with a proposed October 1, 2027 compliance date.

Which payers would CMS-0062-P cover?

Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, QHP issuers on the federally facilitated exchanges, and, newly, small group market QHP issuers on the FF-SHOP exchanges, with a proposed compliance date of plan years beginning on or after January 1, 2028 for the small group issuers.

Sources
  1. Federal Register public inspection, CMS-0062-P, Medicare and Medicaid Programs; Patient Protection and Affordable Care Act; Interoperability Standards and Prior Authorization for Drugs, proposed rule (published April 14, 2026)
  2. CMS fact sheet, CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), January 17, 2024: drug exclusion, decision timeframes
  3. CMS, Electronic Prior Authorization overview (page updated October 21, 2026): CMS-0062-P release date, provider steps for Part D electronic prior authorization

Checked October 25, 2026. Rules change; confirm against the source before relying on them. Items marked proposed are not final until the final rule publishes.

Related
CapabilityPrior authorization automationCapabilityAI eligibility verificationSuiteThe ASP-RCM AI suiteBlogAutomated prior authorization 2027: API, voice or portalNewsletterThe CorePulse Brief: prior auth API day oneWhite paperEligibility system buyer's guide 2027InsightCMS-0057-F deadline clock

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