Prior Authorization Relief Act

This bill, known as the Prior Authorization Relief Act, aims to reform prior authorization processes within the Medicare Advantage program. It directs the Secretary of Health and Human Services to conduct an audit by January 1, 2027, identifying items, services, and Part D drugs that are high-reimbursement, have sufficient clinical evidence for standard policies, and require an excessive number of steps for prior authorization. Following this audit, by May 1, 2028, the Secretary must issue a final rule to standardize prior authorization requirements for these identified items across all Medicare Advantage plans. A significant provision of the bill introduces an exemption from these standardized requirements for providers participating in two-sided risk models, such as accountable care organizations, where they bear both potential losses and gains. This means prior authorization would not be required for services or drugs prescribed by these specific providers. However, Medicare Advantage organizations retain the ability to request that this exemption not apply, allowing their existing prior authorization requirements to remain in effect for their enrollees.