A New Insurance Plan: Does the Old Prior Authorization Transfer?

A patient two years into maintenance therapy with a specialty biologic changes jobs effective December 1. The new employer health plan uses a different commercial insurance carrier and places that specific biologic behind mandatory prior authorization and two-step fail-first step therapy. Does the formal approval letter issued by the patient's previous insurance plan count for anything at the new carrier, and what should the prescribing physician's market access team assemble before the new coverage takes effect?

No. A prior authorization is a legal and administrative determination made by one specific health plan under a single subscriber contract, plan year, and formulary design. It explicitly names one payer, one plan code, one member identification number, and one defined coverage duration. It binds no other payer, not even a different plan administered by the same parent insurance carrier. When health coverage switches, the existing authorization does not automatically travel across the payer boundary as an active entitlement. What happens after the switch depends entirely on the governing coverage program:

• Medicare Advantage Coordinated Care Plans: Must provide a minimum 90-day transition period for any enrollee in an active course of treatment, during which the new plan 'must not disrupt or require reauthorization' for that course, applying even to out-of-network providers under 42 CFR 422.112(b)(8).

• Medicare Part D Prescription Drug Plans: Must operate a transition process that, during the first 90 days of coverage under a new plan, provides a one-time temporary supply of at least an approved month's supply of the needed Part D drug under 42 CFR 423.120(b)(3), with written notice generally within 3 business days of the fill. That fill is not an ongoing authorization.

• Commercial Employer & Individual Plans: Under a voluntary pledge AHIP and the Blue Cross Blue Shield Association announced on June 23, 2025, effective January 1, 2026, participating plans honor existing authorizations for benefit-equivalent, in-network services during a 90-day transition window. The pledge is not a statute, and plans that did not join are outside it.

• Medicaid Managed Care Organizations (MCOs): Honor predecessor authorizations only for the window in that state's managed-care contract. One national MCO family's published policy uses up to 90 days; some state addenda are shorter. There is no single federal Medicaid honoring period.

• State Statutory Mandates: Some state insurance codes require a fully insured plan to honor a documented predecessor authorization for a set window. Tennessee's compiled citation is Tenn. Code Ann. § 56-7-3714, and Illinois's is 215 ILCS 200/70. Those statutes do not bind every ERISA self-funded plan. Tennessee's act also excludes TennCare and CoverKids.

Crucially, none of these transition buffers permanently adopts the predecessor plan's approval. What survives the switch is the clinical record: the prior approval letter, the specific criteria it fulfilled, the objective diagnostic baseline, and documented treatment response. That record serves as the foundational evidence packet required to build an affirmative reauthorization request under the incoming plan's own utilization management criteria.

What a prior authorization actually is - and who it binds

To understand why an existing approval fails to cross health insurance boundaries automatically, access teams must examine what a prior authorization actually represents in healthcare law and managed care administration. Prior authorization is not a property right, portable credential, or clinical license attached to the patient. It is a conditional pre-service determination issued by a specific utilization review organization (URO) or health plan administrator acting on behalf of a designated risk-bearing fiduciary.

Every written prior authorization approval notice contains discrete administrative identifiers that delineate its strict contractual limits. These elements include:

• Payer and Plan Identifiers: The specific legal underwriter, carrier operating entity, group number, and Pharmacy Benefit Manager (PBM) BIN/PCN/RxGroup combinations that fund the claim.

• Subscriber and Member ID: The unique policyholder contract number that validates active enrollment and premium payment for that specific covered life.

• Clinical Coding Scope: The exact Healthcare Common Procedure Coding System (HCPCS) J-code or National Drug Code (NDC), approved strength, route of administration, and allowable dosing frequency.

• Temporal Validity Boundary: An explicit authorization window—typically 6 or 12 months—specifying a firm start date and an expiration date tied to active policy enrollment.

When a patient leaves a health plan—through a job change, open enrollment, retirement, or a Medicaid eligibility change—the contract that produced the prior authorization ends with that enrollment. The letter was permission to bill that plan. It is not a debt the next plan inherits. Where ERISA applies, a plan fiduciary owes duties to that plan's own participants, not to another carrier's utilization-review file. Individual-market coverage and government programs are not ERISA plans. There is no general statute that makes every new payer adopt another carrier's approval as its own. The duties that do exist are program-specific and time-limited, and the sections below set them out.

An authorization letter that still shows months remaining is valid only while the patient stays enrolled in the plan that issued it. When that enrollment ends, the letter is no longer permission to bill the old plan, and it is not permission to bill the new plan. What remains is the record: the drug or service that was approved, the criteria the old plan applied, and the dates of treatment. Later sections describe when a new plan must temporarily honor that record and when the team has to file a new request.

The default after a plan change: a new request under new rules

When a patient enters a new health plan, the administrative baseline from the perspective of the incoming claims processor is effectively blank. Unless a statutory transition rule, mandatory regulatory safeguard, or voluntary carrier protocol intervenes, any pharmacy claim or medical buy-and-bill submission for a restricted specialty therapy will trigger an immediate rejection code, such as NCPDP Reject 75 (Prior Authorization Required).

A frequent point of confusion for patients and provider practices is the assumption that staying with the same recognizable insurance brand guarantees continuity. When an employee moves from one company to another, both employers might offer plans branded under the same national insurer (for example, Blue Cross Blue Shield, UnitedHealthcare, Cigna, or Aetna). However, 'same carrier logo' almost never means 'same plan rules.' One employer may sponsor a self-funded Administrative Services Only (ASO) benefit design with an open specialty formulary, while the second employer sponsors a fully insured commercial policy enforcing an aggressive closed formulary managed by a different PBM with restrictive step therapy requirements.

As detailed in PharmaDossier's analysis of benefit verification for specialty drugs, the channel routing itself may differ entirely between payers. A physician-administered biologic billed under the medical benefit (buy-and-bill or white-bagging) under the prior plan may be routed strictly through the specialty pharmacy benefit under the new plan, requiring separate prior authorization criteria and distribution channels. Similarly, as discussed in our examination of how a formulary change notice differs from a patient-level coverage decision, formulary tiering and clinical restrictions reflect plan-wide benefit designs that operate independently of an individual patient's clinical stability.

A plan change can put a stabilized patient back at the start of utilization management. In the American Medical Association's 2024 prior authorization survey — 1,000 physicians who complete prior authorizations, surveyed in December 2024 — 89 percent said prior authorization interferes with continuity of care, and 61 percent said it at least sometimes destabilizes a patient whose condition had been stabilized on a treatment plan. Those are physician-reported experiences, not a rate at which plans honor a predecessor approval. When the prescription also changes dispensing channel, use the record workflow in the guide on specialty pharmacy transfers and pending prior authorizations.

Medicare Advantage: the mandatory 90-day transition rule

The strongest federal protection against coverage disruption during a plan switch exists within Medicare Advantage. Under the Centers for Medicare & Medicaid Services (CMS) Contract Year 2024 Policy and Technical Changes Final Rule (CMS-4201-F), CMS established an explicit continuity-of-care mandate codified at 42 CFR 422.112(b)(8).

The duty in 42 CFR 422.112(b)(8) applies to coordinated care plans — health maintenance organizations, preferred provider organizations, and regional PPOs — for basic benefits, when the plan uses prior authorization. It is a minimum 90-day transition for an enrollee who was already in an active course of treatment and then enrolled in the Medicare Advantage plan, including someone new to Medicare. The regulatory text says the new Medicare Advantage organization 'must not disrupt or require reauthorization for an active course of treatment for new plan enrollees for at least 90 days'. This mandatory transition applies regardless of whether the enrollee switched from Original Medicare (fee-for-service) or from another Medicare Advantage organization, and it applies even if the enrollee is entirely new to Medicare.

Crucially, 42 CFR 422.112(b)(8) explicitly mandates that the 90-day transition protection applies even if the service is furnished by an out-of-network provider. If a beneficiary joins a new Medicare Advantage plan whose provider network excludes their treating specialist or infusion center, the plan cannot withhold authorization or deny payment for the active treatment regimen during the initial 90-day window. Furthermore, CMS finalized in the rule that approval of a prior authorization request for a course of treatment must be valid for as long as medically necessary to avoid disruptions in care.

In the preamble to the CY 2024 Final Rule, CMS specifically addressed specialty pharmaceuticals, clarifying that an active course of treatment encompasses physician-administered drugs covered under Medicare Part B, such as intravenous biologic infusions, chemotherapy regimens, and intravitreal eye injections. However, the protection has defined temporal boundaries: once the 90-day transition period elapses, the Medicare Advantage plan is fully entitled to reassess medical necessity against its own clinical criteria, apply its standard network restrictions, and require a formal prior authorization under its own contracted policies.

Part D drugs: a transition fill, not a transfer

While Medicare Advantage Part B drugs enjoy the 90-day course-of-treatment protection under 42 CFR 422.112(b)(8), prescription drugs covered under Medicare Part D operate under a separate, highly structured regulatory mechanism codified at 42 CFR 423.120(b)(3). It is essential for access teams to distinguish a Part D transition process from a prior authorization transfer.

Under 42 CFR 423.120(b)(3), all Part D plan sponsors must maintain a transition process for new enrollees and enrollees switching plans. During the first 90 days of coverage under the new plan, the sponsor must provide a one-time temporary supply of at least an approved month's supply of medication (unless the prescription is written for fewer days). This safeguard applies across all pharmacy dispensing channels, including retail community pharmacies, home infusion, mail-order pharmacies, and long-term care facilities (where multiple supplies of 14 days or less may be dispensed to prevent waste).

The Part D transition fill is triggered automatically at point-of-sale when a prescribed drug is not on the new plan's formulary, or is on the formulary but subject to utilization management requirements such as prior authorization or step therapy. Generally within three business days after the temporary fill adjudicates, the Part D sponsor must send the enrollee a written notice detailing:

1. The temporary nature of the transition supply and that future fills will not be covered automatically.

2. Therapeutically appropriate formulary alternatives available on the new plan's drug list.

3. The procedures for requesting a formal coverage determination, formulary exception, or prior authorization with the prescribing physician's supporting statement.

Commercial and Medicaid managed care: the January 2026 commitments

Commercial employer-sponsored and individual-market plans still have no general federal statute that requires a new carrier to honor a predecessor prior authorization. Participating plans made a voluntary commitment, announced by AHIP and the Blue Cross Blue Shield Association on June 23, 2025, effective January 1, 2026. HHS and CMS hosted those insurers the same day. The pledge is the plans' commitment, not an HHS or CMS regulation, and plans that did not join are outside it.

Under these commitments, participating commercial health insurance plans agreed that when an enrollee changes insurance companies during an active course of treatment, the new plan will honor existing prior authorizations for a 90-day transition period. AHIP said the commitments apply across commercial coverage, Medicare Advantage, and Medicaid managed care, consistent with state and federal law, and would benefit 257 million Americans. That figure is the plans' description of covered lives. It is not a count of every commercially insured person, and it does not make the pledge enforceable the way 42 CFR 422.112(b)(8) is.

However, access professionals must examine the critical operational caveats that govern these voluntary commitments. Honoring an existing authorization is subject to three strict conditions:

• Benefit-Equivalent Service: The service, procedure, or medication must be an included covered benefit under the new plan's certificate of coverage. If an employer's benefit package excludes entire therapeutic categories (such as anti-obesity medications or fertility treatments), the voluntary pledge does not override the benefit exclusion.

• In-Network Provider Status: The commitment primarily covers services delivered by participating, in-network healthcare providers and facilities. Out-of-network administrations are evaluated under standard out-of-network plan rules.

• Formulary Exclusions & Non-Covered Drugs: When a prescribed medication is entirely non-formulary on the new plan's drug list, the carrier does not guarantee automated 90-day honoring; instead, the case is evaluated on an individual, case-by-case basis through formulary exception channels.

Continuity under the pledge usually starts with the patient, the prescriber, or the specialty pharmacy, because the new plan often receives enrollment data without the old authorization file. Where the new plan already knows the former plan, AHIP says some plans can exchange authorization data directly. That exchange is not an automatic approval. On April 7, 2026, AHIP and BCBSA reported that participating plans had achieved an 11 percent reduction in prior authorizations across a range of medical services — about 6.5 million fewer authorizations, including a reduction of more than 15 percent in Medicare Advantage. The April 7 update describes that reduction as applying to medical services. It is not a measured drop in prescription-drug prior authorization. The same update said many plans were using secure data-sharing and dedicated continuity-of-care service lines. It did not audit how often a drug authorization was honored.

Medicaid plan changes: honoring windows are contract terms

In Medicaid managed care, transition-of-care rules are not uniform across the United States. Instead, they are defined by state-specific procurement contracts executed between the State Medicaid Agency and contracted Managed Care Organizations (MCOs). Federal Medicaid managed-care rules expect a transition-of-care process. The number of days a predecessor prior authorization is honored is set in the state contract and the plan's utilization-management policy.

One documented example is Policy UM.700, posted with the AmeriHealth Caritas Louisiana provider materials. It is one MCO family's policy plus a Louisiana addendum, not a national Medicaid rule. Under that policy, the plan honors written documentation of a prior authorization for ongoing covered services for up to 90 days following the enrollment effective date, or for the specific timeframe prescribed by the state regulator. During that window, the posted policy keeps ongoing covered services available while clinical teams assess continued medical necessity.

State-specific contractual addenda often refine these timelines. For instance, in Louisiana Medicaid, newly enrolled MCO members receiving active treatments under an existing prior authorization are entitled to receive services without medical necessity review for an initial 30 days, and for up to 30 additional days if the reauthorization review is still pending. The same Louisiana addendum honors prior authorizations for durable medical equipment, prosthetics, orthotics, and certain supplies issued by another MCO or Medicaid fee-for-service for 90 calendar days after enrollment. The policy says utilization management includes querying the relinquishing MCO for open authorizations. Sending the approval notice is still the practical way to put a readable file in front of the new plan. The policy's stated next-review date is May 2025, which is earlier than this article, so confirm the current state addendum before relying on a day count.

State statutes that make honoring mandatory

Several states make a time-limited honoring duty enforceable for the plans their insurance codes cover. Tennessee's Prior Authorization Fairness Act is Public Chapter 395 (2023), effective January 1, 2025. Cite the compiled section, Tenn. Code Ann. § 56-7-3714. Public Chapter 395 printed that section as § 56-7-3614 in part 36. The code commission compiled the new part as part 37, and a later Tennessee bill cites § 56-7-3714 as the existing transfer rule. The code host linked in Sources still displays the act's original part 36 numbering. Use § 56-7-3714 in payer correspondence, and keep the enrolled-act text if a reviewer asks for the session-law wording.

The Tennessee statute establishes an explicit, legally binding continuity mandate: upon receipt of information documenting an approved prior authorization from an enrollee or their healthcare provider, a prior authorization granted by a previous health carrier or utilization review organization must be honored for at least the initial 90 days of the enrollee's coverage under a new health benefit plan. During this statutory 90-day window, the new carrier is permitted to perform its own utilization review, but any modification or denial resulting from that review cannot take effect until the initial 90-day period has expired.

Furthermore, the Tennessee statute includes a critical protection for intra-carrier plan shifts: a carrier is legally required to continue to honor a prior authorization it has already granted when the enrollee changes plans carried or administered by the same carrier. That sentence does not create a new 12-month approval on the receiving plan. A separate subsection says a change in coverage or approval criteria must not affect an enrollee who received prior authorization before the change, for the remainder of that enrollee's plan year.

Illinois and Wyoming have plan-switch rules with different qualifiers. Under 215 ILCS 200/70, effective January 1, 2022, an Illinois health insurance issuer must, once the enrollee or provider documents the prior approval, honor a prior authorization from a previous issuer for at least the first 90 days under a new health plan, subject to the member's coverage agreement. The issuer may perform its own review during that window. The section does not require the new policy to cover a benefit it completely excludes, except as a prescription-drug medical-exception process otherwise requires. Wyoming Statutes § 26-55-111 requires an insurer or contracted utilization-review entity, after receiving the necessary documentation, to honor an authorization from a previous insurer for at least 90 days after the new plan starts, if the service is a covered benefit under the new plan. New Hampshire's 60-business-day rule is a different decision. RSA 420-J:6, IX(a), and the parallel standard in RSA 420-E:4-b, V, both effective January 1, 2025, say a carrier or utilization-review entity shall not revoke, limit, condition, or restrict an approved prior authorization if care is provided within 60 business days after the provider received the approval. The same sections still allow nonpayment when the patient was no longer eligible for that coverage on the day of service. That is a duration rule for an approval the carrier already issued. It is not a duty for a new carrier to honor another carrier's approval. The NAIC committee white paper adopted December 10, 2025 describes a Prior Authorization Model Act adopted November 15, 2025, and recommends that states require honoring a predecessor authorization for a specified period such as 90 days. A model act is not state law until a legislature enacts it. This article is not a 50-state survey.

Read the applicability clause before treating a state honoring statute as universal. Tennessee's own act does not apply to ERISA plans, TennCare, or CoverKids. Public Chapter 395 prints that limit as § 56-7-3620; the compiled code is § 56-7-3720. The exclusion covers a plan subject to ERISA's exclusive jurisdiction, a policy issued under a Bureau of TennCare contract, TennCare itself, and CoverKids. A Tennessee commercial honoring duty is not a TennCare rule. Where a Medicaid managed-care plan honors an old authorization, that duty is in the state contract, not in this commercial statute. For a self-funded employer plan, ERISA preemption often keeps the state insurance mandate off the plan. Use the administrator's own transition policy, including a voluntary AHIP commitment it has actually adopted, and the plan document. Do not tell a self-funded plan that the Tennessee or Illinois statute binds it.

The worked record: what survives the switch

Because transition windows represent temporary buffers rather than permanent approvals, market access teams, specialty hubs, and prescribing clinics must execute a disciplined operational strategy. Understanding which specific data fields on a prior authorization notice are plan-bound versus which fields represent portable clinical evidence is the key to rebuilding an approval packet before the transition window closes.

The following decision table synthesizes the governing legal standards, timeframes, qualifying conditions, and expiration rules across all major healthcare market segments:

When evaluating an existing approval letter, access teams should dissect its components into plan-bound administrative data and portable clinical evidence, as mapped in the illustrative template below:

Intake Checklist for Prescribers and Market Access Teams

Before the coverage effective date, practice coordinators and access teams should assemble a five-part transition packet. Fifteen to 30 days of lead time is a working target when the patient can supply the new card. It is not a rule that guarantees an uninterrupted fill.

1. Full Predecessor Approval Notice: A complete, legible copy of the prior carrier's written approval letter showing the exact drug name, HCPCS/NDC code, approved dosing schedule, and valid-through dates.

2. Baseline Diagnostic & Severity Workup: Historical clinic notes and pathology, imaging, or laboratory results establishing the initial diagnosis and meeting the disease severity thresholds required by specialty drug labels.

3. Historical Step-Therapy Failure Log: Dated documentation of previously tried and failed conventional or preferred formulary medications, explicitly noting trial durations and adverse intolerances or clinical failure. As detailed in PharmaDossier's guide on step therapy exception evidence for specialty drugs, rigorous trial logs prevent new payers from forcing stabilized patients back to generic or biosimilar steps.

4. Objective Disease Stabilization Evidence: Recent clinical progress notes documenting sustained disease control, symptom remission, and functional improvement on current therapy. This documentation is vital to defeat renewal denials based on 'stable disease,' as analyzed in our review of renewal denials for stable disease and continued therapy.

5. 12-Month Dispensing & Administration History: Pharmacy dispensing records or infusion logs showing the dates of recent fills or administrations on the current course. Do not add an adherence percentage the new plan has not published in its criteria.

Chronological Pre-Switch Action Protocol

Prescriber practices and health-system specialty pharmacies should execute the following timeline relative to the new coverage effective date (Day 0):

• T-30 to T-15 Days (Pre-Effective Window): Identify the upcoming insurance transition during routine patient check-ins or benefit renewals. Collect the new insurance card or policy documentation. Request the incoming plan's formulary list, utilization management guidelines, and specialty pharmacy network requirements.

• T-14 to Day 0 (Submission Readiness): Submit a proactive transition-of-care request to the new carrier referencing the AHIP 90-day commitment, 42 CFR 422.112(b)(8) for Medicare Advantage, or applicable state law. Include the complete five-part intake packet. If the new plan allows pre-effective submissions, submit the formal prior authorization request immediately.

• Day 1 to Day 15 (Claims Adjudication Verification): Submit the initial prescription fill or medical infusion claim. If rejected, immediately escalate to the carrier's dedicated continuity-of-care unit, providing the prior authorization approval notice and requesting a 90-day override bridge.

• Day 30 to Day 45 (Reauthorization Packet Submission): Do not wait for the 90-day transition window to run out. Submit the complete, formal prior authorization request under the new plan's specific clinical coverage policy, incorporating full baseline failure data and disease stabilization metrics.

• Day 60 to Day 90 (Affirmative Determination Lock): Track the new plan's determination and get it in writing before the transition window ends. The new approval lasts for the period that plan grants, which may be shorter than a year. If the plan denies the request, appeal under the rules for that coverage: a Medicare Advantage organization determination, a Part D coverage determination, a Medicaid managed-care appeal, or the ERISA claims procedure and any state external review that applies to fully insured commercial coverage. CMS-0057-F is not the appeal statute.

flowchart TD
    A["Patient changes health plan"] --> B{"Which program covers the drug or service?"}
    B -->|"Medicare Advantage coordinated care, basic benefit"| C["42 CFR 422.112(b)(8): at least 90 days without reauthorization"]
    B -->|"Medicare Part D"| D["42 CFR 423.120(b)(3): one temporary fill of at least an approved month's supply"]
    B -->|"Participating commercial plan"| E["Voluntary AHIP and BCBSA pledge: 90 days if benefit-equivalent and in network"]
    B -->|"Medicaid managed care"| F["State-contract window; confirm the current MCO policy"]
    B -->|"State honoring statute applies"| G["Use that statute's window and its exemptions"]
    C --> H["Present the old approval as evidence"]
    D --> H
    E --> H
    F --> H
    G --> H
    H --> I["Assemble the record and file the new plan's own request before the window ends"]
    I --> J{"New plan determination"}
    J -->|"Approved"| K["Authorization only for the period that plan grants"]
    J -->|"Denied"| L["Appeal under that program's own rules"]

2026-2027: faster decisions, portable data, still not a portable approval

The regulatory infrastructure surrounding prior authorization is undergoing historic structural changes driven by the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F). Access teams must understand how these modern rules alter the timing of decisions and the transmission of data, while remaining clear on their explicit legal limitations.

Beginning in 2026, CMS-0057-F requires impacted payers other than qualified-health-plan issuers on the Federally-facilitated Exchanges to send prior-authorization decisions on a set clock. Impacted payers are Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid and CHIP managed-care plans, and those exchange issuers. The clocks exclude the exchange issuers. The fact sheet says the final rule's prior-authorization policies, including these clocks, do not apply to drugs:

• Expedited Decisions: For a non-drug request, a payer subject to the clock must send an expedited decision within 72 hours. Federally-facilitated Exchange issuers are outside this timeframe, and drug prior authorization is outside the rule.

• Standard Decisions: For a non-drug request, the same payers must send a standard decision within 7 calendar days. Federally-facilitated Exchange issuers are outside this timeframe as well. A drug request keeps the decision clock of the program that covers the drug.

• Mandatory Specific Denial Reasons: Beginning in 2026, impacted payers must give a specific reason for a denied prior authorization, whether the request arrived by portal, fax, email, mail, or phone. The fact sheet says this provision, like the rest of the final rule, does not apply to drug prior authorization. Existing written-notice rules, including Medicare's, still apply on top of this requirement.

• Public Prior-Authorization Metrics: Impacted payers must post certain prior-authorization metrics on their websites each year. The initial set was due March 31, 2026. Those metrics follow the rule's scope, which excludes drug prior authorization.

Looking forward to January 1, 2027, CMS-0057-F requires impacted payers to implement a Prior Authorization API and to add specified prior-authorization information to the Patient Access, Provider Access, and Payer-to-Payer APIs. The Prior Authorization API must be able to list covered items and services, identify documentation requirements, and return the payer's response: an approval and the date or circumstance when it ends, a denial with a specific reason, or a request for more information. That is an electronic response from the payer, not an automated clinical approval. On the Payer-to-Payer API, exchange happens after the patient opts in. The data are claims and encounters (without remittances and cost sharing), USCDI data, and specified prior-authorization information with a date of service within five years of the request. Receiving that file does not enroll the patient in the old approval.

The definitive strategic reality for healthcare providers and specialty access teams is that data portability is not approval portability. The 2026 and 2027 rules speed some non-drug decisions and can move a historical record. They do not make a commercial payer adopt another carrier's approval as its own ongoing authorization. Use the transition window as a temporary bridge, assemble the evidence packet, and file the new plan's own request before the window closes. That sequence reduces avoidable gaps. It does not guarantee that the new plan will approve the drug.

Sources

Records checked for this article, accessed September 29, 2026. Federal duties are cited to the eCFR, the Federal Register, and CMS fact sheets. The commercial 90-day honoring language is the plans' voluntary commitment. The Tennessee link below is a code host that still displays Public Chapter 395's original part 36 numbering; the compiled citation is Tenn. Code Ann. § 56-7-3714. The Medicaid example is one plan's posted policy. The NAIC paper and the AMA article are secondary summaries.

• 42 CFR 423.120 - Access to covered Part D drugs (transition process at (b)(3)) — eCFR / Office of the Federal Register.

• 42 CFR 422.112 - Access to services (prior-authorization transition at (b)(8)) — eCFR / Office of the Federal Register.

• Contract Year 2024 Policy and Technical Changes to the Medicare Advantage Program and Medicare Prescription Drug Benefit Program (Final Rule preamble) — Federal Register / Centers for Medicare & Medicaid Services (CMS-4201-F).

• 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F) fact sheet — Centers for Medicare & Medicaid Services.

• CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) fact sheet — Centers for Medicare & Medicaid Services.

• Health Plans Take Action to Simplify Prior Authorization (press release, June 23, 2025) — AHIP.

• Health Plans Reduce Prior Authorization, Support Continuity of Care and Enhanced Consumer Communications (April 7, 2026) — AHIP.

• Health Plans Are on Track to Streamline Prior Authorization — AHIP.

• Prior Authorization White Paper (adopted by NAIC committee, December 10, 2025) — National Association of Insurance Commissioners.

• Tennessee Prior Authorization Fairness Act host text (enrolled numbering; compiled section is Tenn. Code Ann. § 56-7-3714) — Managed Care Legal Database.

• UM.700 Provider-Member Transition of Care / Continuity of Care policy (AmeriHealth Caritas family of companies) — AmeriHealth Caritas.

• Fixing prior auth: We must ensure continuity of care — American Medical Association.