ePA Blog

Electronic Prior Authorization: Modernizing Pharmacy Workflows
Prior authorization has been an effective method to curb unnecessary spending.   While ePA has streamlined approvals, reduced delays, and enabled patients to get medications faster, challenges remain for all stakeholders in the pharmaceutical ecosystem.  In this series of blog posts, paPAyaRx Solutions shares research, findings and perspectives on ePA trends and the changing landscape.  
New Post  JUly 6, 2026
ePA Challenge for PBMs and Health Plans
How rising administrative costs, evolving legislation, and new technology solutions are reshaping prescription drug management.
Prior authorization (PA) has long been a critical tool for Pharmacy Benefit Managers (PBMs) and health plans. By ensuring that certain medications are medically necessary, clinically appropriate, and aligned with formulary requirements, PA programs help control drug spending while promoting safe and effective care.
Yet as specialty medications, high-cost therapies, and complex benefit designs continue to grow, electronic prior authorization (ePA) has emerged as both an opportunity and a challenge. While digital workflows promise greater efficiency than traditional fax and phone-based processes, many PBMs and health plans are discovering that implementing and managing a successful ePA program is far from simple.
For organizations seeking to balance cost containment, provider satisfaction, regulatory compliance, and member access, the electronic prior authorization landscape continues to present significant operational and strategic hurdles.
The True Cost of Managing Prior Authorization Programs
Many healthcare stakeholders view prior authorization primarily as a clinical management function. In reality, it is also a substantial administrative undertaking.
Behind every approval, denial, or request for additional information lies a complex ecosystem involving:
Clinical review teams
Pharmacists and medical directors
Provider outreach staff
Technology infrastructure
Vendor management
Regulatory compliance personnel
Reporting and analytics teams
As prescription drug utilization increases, so does the volume of PA requests. Specialty medications in particular often require extensive documentation, clinical validation, and ongoing monitoring.
For PBMs and health plans, the costs include:
Technology Infrastructure
Maintaining an ePA platform requires ongoing investment in:
Network connectivity
System integrations
Security and compliance controls
Data management and reporting
Electronic health record (EHR) interoperability
These systems must be available at scale while maintaining high performance and uptime.
Administrative Labor
Even highly automated programs frequently require manual intervention when:
Clinical information is missing
Coverage criteria are unclear
Provider data is incomplete
Appeals are submitted
Benefit structures vary across plans
Manual reviews can significantly increase processing costs and turnaround times.
Provider Support
PBMs and health plans must dedicate resources to provider education, training, and support. Physicians often work with multiple health plans, each with unique prior authorization requirements, creating confusion and increased call center volume.
Compliance and Auditing
Regulatory oversight continues to expand. Organizations must maintain comprehensive audit trails, monitor turnaround times, and demonstrate compliance with federal and state requirements.
The result is that many prior authorization programs cost far more to administer than stakeholders initially anticipate.
Why Electronic Prior Authorization Still Isn't Easy
Electronic prior authorization was introduced to replace paper forms, faxes, and phone calls with streamlined digital workflows. While adoption continues to rise, several challenges remain.
Fragmented Workflows
Healthcare providers work across multiple EHR systems. PBMs and health plans often use different adjudication and utilization management platforms.
Without seamless interoperability, information must be transferred between systems, creating delays and increasing administrative burden.
Inconsistent Clinical Rules
Each PBM and health plan may define coverage requirements differently.
Providers frequently encounter variations in:
Step therapy requirements
Quantity limits
Clinical documentation standards
Specialty drug criteria
These inconsistencies can create friction and reduce the efficiency gains ePA was intended to deliver.
Data Quality Issues
Electronic submissions can only be automated when the required clinical data is available in a structured format.
Unfortunately, key information often exists only in clinical notes or unstructured documentation, leading to manual reviews and longer decision times.
Provider Adoption
Some provider organizations have fully integrated ePA into their workflows, while others continue to rely on traditional processes.
This mixed environment requires PBMs and health plans to support multiple submission channels simultaneously.
A New Regulatory Environment
Adding complexity to the situation is a rapidly changing regulatory landscape.
Federal and state policymakers have increasingly focused on PBM transparency, administrative fees, spread pricing, rebate management, and pharmacy reimbursement practices.
Recent PBM reform initiatives have proposed or implemented measures designed to:
Increase transparency of PBM compensation
Limit certain fee structures
Restrict spread pricing practices
Require rebate pass-through arrangements
Enhance reporting and audit requirements
Strengthen oversight of administrative activities 
These reforms are intended to improve accountability and reduce costs for plan sponsors and patients. However, they may also reduce traditional revenue streams for some PBMs while increasing compliance obligations. 
As a result, organizations are under pressure to operate more efficiently while maintaining service levels and regulatory compliance.
For many PBMs and health plans, this creates a compelling business case for modernizing prior authorization operations.
The Future of Prior Authorization
The healthcare industry is moving toward a future where prior authorization becomes more integrated, data-driven, and automated.
Success will depend on the ability of PBMs and health plans to balance four critical objectives:
Managing rising drug costs
Ensuring timely patient access to therapy
Reducing administrative burden
Meeting evolving regulatory requirements
Electronic prior authorization remains one of the most effective tools for achieving these goals—but only when supported by efficient technology, streamlined workflows, and experienced operational partners.
Conclusion
As prescription drug spending continues to rise and regulatory scrutiny intensifies, PBMs and health plans face increasing pressure to deliver prior authorization programs that are efficient, compliant, and provider-friendly.
The challenge is no longer simply determining whether prior authorization should be used. The real question is how organizations can administer these programs effectively without creating excessive cost, complexity, and frustration.
Organizations that leverage automation, interoperability, and expert operational support will be best positioned to reduce administrative expenses, improve turnaround times, and achieve better outcomes for both members and providers.
For PBMs and health plans, the future of prior authorization is not just electronic—it is intelligent, connected, and built for scale.
New Post  July 6, 2026
What CMS's 2026 Drug ePA Proposal Means for Pharmacies and Providers 
The biggest change to drug prior authorization in years could dramatically reshape how prescriptions are approved, processed, and dispensed.
On April 10, 2026, the Centers for Medicare & Medicaid Services (CMS) released its Interoperability Standards and Prior Authorization for Drugs Proposed Rule (CMS-0062-P). The proposal extends many of the interoperability and prior authorization requirements established in CMS's 2024 rule for medical services and applies them to prescription drugs for the first time. For pharmacies, prescribing providers, health plans, and PBMs, the proposal represents a significant step toward a future where prior authorization (PA) is fully digital, more transparent, and subject to stricter turnaround requirements. If finalized, many stakeholders will need to modernize workflows, improve system integrations, and prepare for increased operational accountability. 
Why CMS Is Expanding Electronic Prior Authorization
Despite years of investment in electronic prior authorization (ePA), much of the pharmacy benefit ecosystem continues to rely on phone calls, faxes, portals, and manual workflows. CMS believes these inefficiencies contribute to:
Delayed patient access to medications
Provider administrative burden
Increased healthcare costs
Poor visibility into payer performance
The proposed rule aims to create a more consistent, API-driven framework that allows providers and pharmacies to exchange prior authorization information electronically and receive decisions more quickly. 
Benefit 1: Electronic Prior Authorization Would Become the Standard for Drug Benefits
Perhaps the most significant aspect of the proposal is that CMS would extend electronic prior authorization requirements to prescription drugs covered under pharmacy benefits. While the 2024 CMS interoperability rule focused primarily on medical services and non-drug items, the new proposal would require impacted payers to support electronic prior authorization for drugs using modern interoperability standards and APIs. [cms.gov], [beckershos...review.com] For providers, this means:
Less reliance on fax-based workflows
Greater integration within EHR systems
Real-time access to formulary and coverage requirements
Electronic submission and tracking of PA requests
For pharmacies, it creates the potential for more efficient communication between dispensing systems, PBMs, and health plans, reducing prescription abandonment caused by authorization delays.
Benefit 2: Faster Decision Timelines Could Reduce Medication Delays
CMS is also proposing significantly tighter decision timeframes for drug prior authorizations. According to the proposal:
Certain marketplace health plans would be required to respond to standard drug prior authorization requests within 72 hours.
Expedited requests would require decisions within 24 hours.
CMS is also seeking greater alignment across affected programs to reduce variation in response times.
For providers, faster decisions could mean fewer treatment interruptions and reduced staff time spent on follow-up calls. For pharmacies, shorter response times may help reduce the number of prescriptions placed on hold while waiting for authorization decisions. For patients, the proposal has the potential to improve access to necessary medications and reduce delays at the pharmacy counter. 
Benefit 3: Public Prior Authorization Metrics Will Increase Transparency
Another major provision would require impacted payers to publicly report prior authorization performance metrics for prescription drugs. CMS proposes extending its transparency requirements to include reporting on:
Approval and denial rates
Prior authorization volumes
Appeals outcomes
Decision turnaround times
Health plans would be required to publish this information annually, creating greater visibility into how efficiently drug prior authorization programs operate.
This change could have far-reaching implications. For providers and pharmacies, publicly available metrics could help identify plans that consistently create delays or administrative burdens. For health plans and PBMs, the data may create new competitive pressure to improve operational performance. The result may be a stronger focus on automation, workflow optimization, and member experience.
Benefit 4: FHIR APIs Will Become Central to Prior Authorization Operations
The proposal is also heavily focused on modern interoperability standards. CMS and the Office of the National Coordinator for Health Information Technology (ONC) are proposing broader adoption of HL7 Fast Healthcare Interoperability Resources (FHIR) standards and related implementation guides that support electronic prior authorization workflows.  
Proposed standards include:
Coverage Requirements Discovery (CRD)
Documentation Templates and Rules (DTR)
Prior Authorization Support (PAS)
Clinical Data Exchange (CDex)
These standards are designed to allow systems to:
Exchange coverage requirements electronically
Identify documentation requirements earlier
Submit prior authorization requests digitally
Communicate authorization decisions automatically
Rather than requiring providers to leave their EHR or staff to manually complete payer forms, the goal is to bring prior authorization directly into the clinical workflow.
What This Means for Pharmacies
Potential Benefits
Faster PA approvals
Reduced prescription abandonment
Improved patient satisfaction
Better visibility into authorization status
Less manual communication with provider offices
Potential Challenges
Technology upgrades may be required
Pharmacy systems may need stronger connectivity with PBMs and payers
Workflow changes will require staff training
Interim disruption may occur during implementation
The pharmacies that are best positioned for success will be those that invest early in interoperable systems and digital connectivity.
What This Means for Providers
For physicians and clinical staff, the proposal could significantly reduce administrative burden—but only if implementation is executed correctly.
Providers may gain:
Improved EHR integration
Fewer manual forms
Greater visibility into coverage requirements
Faster authorization decisions
However, organizations that continue relying on paper-based processes may face increasing operational challenges as the industry moves toward API-driven prior authorization workflows.
The Bottom Line
CMS's 2026 proposed rule signals a clear direction for the industry: drug prior authorization is moving toward a fully electronic, standards-based ecosystem. By expanding electronic prior authorization requirements to prescription drugs, imposing faster response timelines, requiring public reporting of prior authorization performance, and advancing FHIR-based interoperability standards, CMS is attempting to reduce administrative friction throughout the medication access journey.
For pharmacies and providers, the message is clear: organizations that modernize their prior authorization infrastructure now will be better prepared for the next generation of payer, PBM, and regulatory requirements. The move away from fax machines and manual processes is accelerating, and the CMS proposal may prove to be one of the most influential milestones in that transformation.
Learn how CMS's 2026 proposed drug prior authorization rule could affect pharmacies, providers, PBMs, and health plans through mandatory ePA, faster decision timelines, public reporting requirements, and FHIR-based interoperability standards.

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About This Blog
Our ePA blog covers the full landscape — from health plan strategy to pharmacy operations. Written for payers, PBMs, and pharmacy leaders navigating the shift to electronic workflows.