Prior authorization was a hot topic in 2025, from insurers pledging reforms to a Medicare pilot on the horizon.
Here are five of the biggest stories on prior authorization from 2025:
1. Payers have been working toward meeting requirements for CMS’ Advancing Interoperability and Improving Prior Authorization Final Rule, but progress is still lagging ahead of the 2027 deadline. The rule includes insurers implementing an application programming interface and documenting prior authorization metrics.
2. Evry Health CEO and co-founder Chris Gay suggested that axing prior authorizations could be possible. He said Evry has thought about expanding gold carding, which hinges on strengthening relationships with providers.
3. CVS Health’s Aetna is merging prescriptions and surgical procedures into a single, bundled prior authorization package. For example, its most recent offering is the musculoskeletal bundle, which includes X-rays, knee arthroplasty surgical procedures, antinausea and nonopioid pain medications, inpatient admission, infection control, and medical equipment. Other offerings include lung, breast and prostate cancer prior authorization bundles.
4. A prior authorization pilot is coming to Medicare in 2026, with providers in Arizona, Washington, New Jersey, Texas, Ohio and Oklahoma testing the new protocol. The initiative — especially its use of AI — has received backlash from some organizations, while a handful of Democratic lawmakers are pushing to cancel the pilot.
5. This summer, about 50 insurers pledged to simplify prior authorization, with some reductions starting in the new year.
