The Friction of Care: Why Prior Authorization Reform Must Work at the Pharmacy Counter

Pharmacists are often the first health care professionals to experience the real-world consequences of prior authorization failures—at the exact point where coverage decisions collide with patient care. Across Massachusetts and the rest of the country, prior authorization has evolved from a utilization management tool into a persistent source of delay, confusion, and fragmented care. What was once designed to manage cost now routinely interferes with continuity of therapy, placing pharmacists in the difficult position of explaining administrative barriers they did not create and cannot resolve.

For decades, pharmacists have witnessed how prior authorization requirements disrupt care delivery. The current framework has shifted away from clinical oversight toward insurer- and pharmacy benefit manager (PBM)–driven administrative control. The result is a system in which approvals are frequently disconnected from real-time clinical needs, forcing pharmacists to manage the fallout—bridging therapy, navigating exceptions, and absorbing patient frustration—while having little authority over the underlying decisions. This is no longer a background administrative issue; it is an operational failure that directly affects patient access.

Continuity of Care Must Be a Baseline Standard

One of the most pressing gaps in the prior authorization system arises when patients transition between insurance plans. A patient’s medical necessity does not expire when coverage changes, yet access to treatment often does. For pharmacists, these transitions frequently result in abrupt therapy interruptions, emergency overrides, and repeated patient callbacks—despite the treatment having already been deemed clinically appropriate.

Several states have addressed this disconnect by codifying continuity-of-care protections. Illinois and Vermont require insurers to honor existing prior authorizations for at least 90 days following a coverage change.^1,2 Massachusetts’ updated regulations for 2026 include a 3-month continuity period for transitions, signaling recognition of the issue.³ Embedding these protections in statute would ensure that patients with chronic conditions are not forced into avoidable gaps in therapy simply because their insurance card changes.

Operationalizing Clinical Trust: Gold Carding and True Peer Review

Prior authorization decisions are only as credible as the processes behind them. Too often, pharmacists and prescribers encounter denials issued through “peer review” processes that lack true clinical alignment—where a specialist’s treatment plan is evaluated by a reviewer without equivalent expertise. Legislation should require meaningful peer review standards, including defined licensure, specialty-specific qualifications, and transparency around reviewer credentials.

Several states are moving in this direction. Wyoming has implemented a “gold card” program that exempts clinicians with high approval rates from repetitive prior authorization requirements.⁴ Colorado has adopted similar alternative approval pathways, while California has established fiduciary obligations for PBMs, reinforcing that coverage decisions must be made fairly and in the patient’s interest.^5,6 For pharmacists, these models represent a shift toward recognizing consistent, evidence-based clinical decision-making rather than forcing repeated administrative validation.

The Digital Imperative—and Its Limitations

At the federal level, the CMS-0057-F Final Rule signals a clear move toward electronic prior authorization through Fast Healthcare Interoperability Resources–based application programming interfaces and standardized data exchange. Maryland has taken an aggressive approach, requiring payers to integrate electronic prior authorization processes with electronic health records and provide real-time benefit data by July 2026.⁷ This direction holds promise, but it also presents challenges that pharmacists understand well.

Faster electronic systems only improve care if the information they deliver is accurate and actionable at the point of dispensing. Coverage stage confusion under Medicare Part D, incomplete formulary data, and inconsistencies for dual-eligible patients can undermine the value of real-time benefit tools. Without clear guardrails, electronic prior authorization risks becoming a faster version of the same opaque denial process.

Massachusetts has an opportunity to harmonize state law with federal momentum by mandating secure, interoperable electronic prior authorization standards while preserving accuracy and accountability. Requirements such as timely responses for urgent cases and clear communication of formulary alternatives must be shared responsibilities among payers, PBMs, and providers—not burdens placed solely on pharmacies.

Breaking the Cycle of Repetitive Authorizations

For patients with stable, chronic conditions, repeated reauthorization of maintenance medications is a systemic inefficiency that benefits no one. Pharmacists routinely manage claim reversals and therapy interruptions for treatments that have already demonstrated effectiveness over months or years. Several states have recognized this problem and acted accordingly.

Illinois prohibits insurers from requiring prior authorization for drugs when a patient has remained stable for 6 months.¹ Colorado extends valid authorization periods for chronic medications to 3 years.⁵ Minnesota has limited prior authorization requirements for certain nonmedication aspects of cancer and mental health care.⁹ These approaches acknowledge a simple reality: when clinical stability is established, repeated administrative readjudication adds friction without improving outcomes.

Aligning Policy With Pharmacy Practice

For pharmacists, prior authorization reform is no longer an abstract policy discussion—it is a daily operational reality with direct consequences for patient care. States across the country are demonstrating that thoughtful guardrails can reduce administrative burden while preserving appropriate oversight. Massachusetts now has the opportunity to align legislative intent with pharmacy-level execution, ensuring that coverage decisions support, rather than disrupt, the continuity of care pharmacists work every day to deliver.

REFERENCES

1. 215 ILCS 200 (2024). Accessed February 24, 2026. https://law.justia.com/codes/illinois/chapter-215/act-215-ilcs-200/?utm

2. Vt Stat Ann. H.766 (Act 111) (2024). Accessed February 24, 2026. https://legislature.vermont.gov/bill/status/2024/H.766

3. Kuznitz A. Healey unveils plan to reform health care insurance ‘prior authorization’ requirements. WBUR. January 14, 2026. Accessed February 24, 2026. https://www.wbur.org/news/2026/01/14/healey-unveils-plan-to-reform-health-care-insurance-prior-authorization-requirements?utm

4. Prior authorization. Wyoming Department of Insurance. Accessed February 24, 2026. https://doi.wyo.gov/companies/prior-auth?utm

5. Colo Assemb HB24-1149 (2024). Accessed February 24, 2026. https://leg.colorado.gov/bills/hb24-1149?utm

6. Cal SB 41, ch 605 (2025). Accessed February 24, 2026. https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=202520260SB41&utm

7. CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F). Centers for Medicare & Medicaid Services. Updated September 10, 2025. Accessed February 24, 2026. https://www.cms.gov/cms-interoperability-and-prior-authorization-final-rule-cms-0057-f

8. Draft amendments. Maryland Health Care Commission. October 16, 2025. Accessed February 24, 2026. https://mhcc.maryland.gov/mhcc/pages/home/meeting_schedule/documents/presentations/2025/20251016/ag7a_prior_auth_prst.pdf

9. Focus on new laws: prior authorization reform. Minnesota Ambulatory Surgery Center Association. Accessed February 24, 2026. https://www.mnasca.org/prior-authorization?utm