In June 2025, health insurance industry leaders coordinated with the federal government on a voluntary pledge to streamline prior authorization processes. Beginning in 2026, participating plans committed to reduce the volume of services subject to PA, honor PA approvals from other plans during coverage transitions, and provide clear explanations of PA determinations. By 2027, they pledged to enable real-time approvals on most requests and standardize electronic PA submissions.
That pledge sits on top of a federal regulatory framework — the CMS Interoperability and Prior Authorization final rule (CMS-0057-F) and the 2026 proposed rule on PA for drugs (CMS-0062-P) — and a patchwork of state laws that have been accumulating since Texas passed a landmark gold card statute (HB 3459) in 2021, following West Virginia's first-in-the-nation gold card legislation (HB 2351) in 2019.
This article is for manufacturer market access teams, field reimbursement managers, hub operators, specialty pharmacy access coordinators, and payer strategy leads who need to understand which state PA reforms affect specialty drug workflows, how gold carding intersects with pharmacy-benefit PA, and what to prepare for as federal and state requirements converge.
Gold carding: the state landscape in 2026
Gold carding exempts providers with high prior authorization approval rates from PA requirements for specific services. West Virginia was the first state to enact gold card legislation (HB 2351, 2019, implemented 2020). Texas followed with HB 3459 (2021), which was amended in 2025 by HB 3812 and became the model for subsequent state laws.
States with enacted gold card laws
As of early 2026, eight states have enacted gold carding legislation:
| State | Law | Approval threshold | Evaluation period | Exemption duration | Includes prescriptions? |
|---|---|---|---|---|---|
| Texas | HB 3459 (2021), amended HB 3812 (2025) | 90% | 12 months (extended from 6 months by 2025 amendment) | 12 months | Limited — TDI-regulated plans; PA for drugs not broadly covered |
| Arkansas | HB 1271 (2023), amended Act 389 (2025) | 80% | 12 months | 12 months | Yes — prescription medications included since January 1, 2025 |
| Michigan | Public Act 60 (2022) | 80% | 12 months | 12 months | Limited — applies to medical services |
| Louisiana | HB 446 (2024) | 80% | 12 months | 12 months | No — prescription medications excluded |
| West Virginia | SB 609 (2024), amended SB 833 (2025) | 90% | 6 months | 12 months | No — prescribing of medication removed by 2025 amendment |
| Wyoming | HB 31 (2024) | 90% | 12 months | 12 months | No — limited to procedures |
| Colorado | HB 24-1149 (2024) | 90% | 12 months | 12 months | Partial — covers dose/frequency adjustments for chronic maintenance drugs |
| Vermont | HB 558 (2024) | 80% | 12 months | 12 months | Limited — applies broadly but formulary-specific implementation varies |
Key differences that matter for specialty drug access
Arkansas is the bellwether for drug inclusion. Arkansas is the only state that explicitly includes prescription medications in its gold card program. Since January 1, 2025, Arkansas gold card exemptions apply to drug PA as well as procedural PA. If replicated in other states, this would be the most significant reform for specialty pharmacy-benefit PA.
Most gold card laws exclude pharmacy-benefit PA. Louisiana, West Virginia, and Wyoming explicitly limit gold carding to procedures and medical services. Michigan's law applies to medical services. In these states, specialty drug PA under the pharmacy benefit remains unaffected by gold carding.
Texas amended but gaps remain. The 2025 amendment extended the evaluation period to 12 months and included claims from products not regulated by the Texas Department of Insurance in gold card evaluations. However, as reported by the Texas Medical Association, fewer than 4% of physicians qualified under the original law, due to inconsistent plan implementation. The 2025 amendments were designed to close some of these gaps.
Private payer gold card programs
Even without state legislation, some payers have implemented gold carding independently:
UnitedHealthcare launched a national Gold Card program in 2025. To qualify, a provider group must meet three criteria for each of the past two consecutive years: in-network for at least one line of business, a minimum of 10 eligible PA requests per year, and a 92% or higher approval rate after appeals. As of April 1, 2026, UHC updated its Gold Card code list, removing certain codes from the PA requirement entirely.
Highmark expanded its Enterprise Gold Carding Program in March 2026, adding 139 CPT codes for a total of 728 Gold Card-enabled codes. Highmark requires a 99% or higher approval rate for select modalities and conducts monthly random and targeted audits.
State PA reform beyond gold carding
States have enacted additional reforms that affect specialty drug PA workflows:
Decision timeframes
| Reform | States | Impact on specialty drug PA |
|---|---|---|
| Standard PA decision within 24–72 hours | Alaska, Nebraska, Montana, North Dakota, Virginia | Applies to all PA, including drug PA. Shorter timeframes reduce patient wait time but may not change approval rates. |
| Urgent PA decision within 24 hours | Multiple states | Standard in most state PA laws. Urgent reviews for acute conditions; may not apply to chronic specialty drug initiation. |
| Retroactive PA denials prohibited | Montana, North Dakota, Virginia | Prevents plans from retroactively denying an approved PA. Protects providers and patients but does not simplify initial PA submission. |
| Deemed approved if no response within specified timeframe | Colorado, others | If the plan does not respond within the statutory timeframe, the PA is automatically approved. This is a pressure valve for delayed decisions. |
Public clinical criteria
Alaska and Nebraska now require carriers to rely on peer-reviewed, evidence-based clinical review criteria and to ensure that adverse determinations are made by qualified clinical peers. This reform targets the transparency of PA criteria rather than the volume of PA requirements. For specialty drug manufacturers, public criteria requirements mean that PA rejection reasons should be more specific and traceable to published clinical evidence, making appeals more targeted.
Chronic condition and maintenance drug protections
Colorado removed additional PA requirements for certain dose and frequency adjustments to previously approved chronic maintenance drugs. Montana prohibits PA for both short- and long-acting insulin. These reforms protect patients already on therapy from reauthorization burden but do not address the initial PA hurdle for new specialty drug starts.
PA validity periods
Arkansas requires that prior authorization remain valid for at least 90 days. Texas requires plans to offer a renewal process, with healthcare providers able to request renewal at least 60 days before the existing authorization expires. These validity-period requirements are particularly relevant for specialty drugs prescribed in 12-month cycles, where reauthorization is needed annually.
Federal regulatory overlay
CMS-0057-F: Interoperability and Prior Authorization final rule
The 2024 final rule (CMS-0057-F) requires Medicare Advantage organizations, Medicaid FFS programs, Medicaid managed care plans, and CHIP entities to:
- Implement a PA API that supports electronic submission and response
- Provide specific reasons for denials
- Report PA metrics publicly
- Make PA decisions within specified timeframes (7 calendar days for standard, 72 hours for expedited)
This rule primarily addresses medical-benefit PA but establishes the infrastructure that subsequent drug-PA rules build on.
CMS-0062-P: Prior Authorization for Drugs proposed rule
The 2026 proposed rule (CMS-0062-P) extends electronic PA requirements to pharmacy-benefit drugs. Key provisions:
- Impacted payers must support three NCPDP standards: SCRIPT, Formulary & Benefit (F&B), and Real-Time Prescription Benefit (RTPB)
- State Medicaid FFS programs must make drug PA decisions within 24 hours
- State CHIP FFS programs must provide PA decisions within 24 hours
- Medicaid managed care plans must align with existing drug PA timeframes
- The proposed rule is open for public comment until June 15, 2026
If finalized, CMS-0062-P would create the first federal electronic PA mandate specifically for drugs, including specialty drugs under the pharmacy benefit. The October 1, 2027 compliance date gives manufacturers and hubs approximately 18 months to prepare.
What manufacturer access teams should do now
1. Do not reduce PA support capacity based on gold carding
Gold carding primarily affects procedural and medical-benefit PA for high-approval providers. Pharmacy-benefit PA for specialty drugs — the domain where manufacturer hub and FRM teams spend most of their effort — remains largely untouched in most states. Even in Arkansas, where drug PA is included, the exemption applies only to providers with high approval rates, and most specialty drug PA is still processed through standard channels.
The operational takeaway from the Rx Almanac state PA reform tracker: "Manufacturers should treat state PA reform as a workflow modifier, not a reason to reduce hub or FRM capacity broadly."
2. Build plan/state/provider status intelligence into BV and PA workflows
Hub teams should capture:
- Whether the patient's plan is subject to state gold carding (depends on whether the plan is fully insured and regulated by the state insurance department)
- Whether the prescriber has gold card status with the specific plan
- The state's PA decision timeframe requirements
- Whether the state prohibits retroactive denials or deems unresponded requests approved
This information is not typically available in standard benefits verification output. Hub teams may need to add a state-law lookup to their screening workflow.
3. Prepare for electronic PA mandates
The CMS-0062-P proposed rule would require electronic PA for pharmacy-benefit drugs by October 2027. Manufacturer access teams should:
- Audit current PA submission workflows for readiness to support NCPDP SCRIPT and RTPB standards
- Confirm that hub platforms can generate and receive electronic PA requests and responses
- Train field reimbursement managers on the new electronic PA workflow
- Monitor the final rule timeline (expected late 2026 or early 2027)
4. Track state legislative sessions for new gold card and PA reform bills
Several states introduced gold card bills in the 2025–2026 legislative session that did not pass, including New York (S7470), Ohio (HB 214), and South Carolina (H 4562). These bills are likely to be reintroduced. The Aimed Alliance 2026 Gold Card Law Analysis catalogs these pending bills and their specific provisions.
5. Differentiate between fully insured and self-funded plans
State PA reform laws apply to fully insured plans regulated by the state insurance department. Self-funded ERISA plans are exempt from state insurance regulation, including gold carding and PA timeframe mandates. For manufacturer access teams, this means that a patient covered by a self-funded employer plan in Texas may not benefit from the Texas gold card law, even though a patient covered by a fully insured plan in the same state would.
State-by-state summary of key PA reforms affecting specialty drug access
| State | Gold carding | Drug PA included | Decision timeframe | Retroactive denials | Public criteria | PA validity |
|---|---|---|---|---|---|---|
| Arkansas | Yes (80%, 12 mo) | Yes (since Jan 2025) | 2 business days (standard), 1 business day (urgent), 72 hours (drugs) | — | — | 90 days minimum |
| Colorado | Yes (90%, 12 mo) | Partial (dose/freq adjustments for chronic drugs) | — | — | — | — |
| Louisiana | Yes (80%, 12 mo) | No | — | — | — | — |
| Michigan | Yes (80%, 12 mo) | No | — | — | — | — |
| Texas | Yes (90%, 12 mo) | Limited | — | — | — | Renewal 60 days before expiry |
| Vermont | Yes (80%, 12 mo) | Limited | — | — | — | — |
| West Virginia | Yes (90%, 6 mo) | No (removed 2025) | — | — | — | — |
| Wyoming | Yes (90%, 12 mo) | No | — | — | — | — |
| Alaska | No | — | — | — | Yes (peer-reviewed, evidence-based) | — |
| Montana | No | — | — | Prohibited | — | — |
| Nebraska | No | — | — | — | Yes (peer-reviewed, evidence-based) | — |
| North Dakota | No | — | — | Prohibited (limited exceptions) | — | — |
| Virginia | No | — | — | Prohibited (limited exceptions) | — | — |
What to monitor next
CMS-0062-P final rule: The proposed drug PA rule is the single most impactful regulatory change for specialty drug PA workflows. Monitor CMS rulemaking through mid-2027.
Arkansas drug gold card outcomes: If Arkansas drug gold card data shows meaningful reductions in PA volume for pharmacy-benefit drugs, other states are likely to replicate the model.
Voluntary payer pledge implementation: The June 2025 industry pledge includes commitments through 2027. Track whether participating plans follow through on real-time approvals and standardized electronic PA.
New state gold card bills: Monitor 2026–2027 legislative sessions for reintroduced bills in New York, Ohio, South Carolina, and other states.
ERISA preemption challenges: If state PA reform laws are challenged as preempted by ERISA for self-funded plans, the scope of gold carding and PA timeframe requirements could narrow significantly.
This article provides general information about state prior authorization reform and its implications for specialty drug access teams. It does not constitute legal advice, compliance guidance, or reimbursement advice for any specific patient, plan, or provider. State laws vary and are subject to change. Always verify current state requirements and plan-specific policies before providing PA guidance.
Sources
- Georgetown University Center on Health Insurance Reforms. "Prior Authorization Reform Heats Up." 2025. https://chir.georgetown.edu/prior-authorization-reform-heats-up
- Aimed Alliance. "Gold Card Law Analysis." January 2026. https://aimedalliance.org/wp-content/uploads/2026/01/AA-GoldCard-Analysis-2026.pdf
- CMS. "2026 CMS Interoperability Standards and Prior Authorization for Drugs Proposed Rule (CMS-0062-P)." https://www.cms.gov/newsroom/fact-sheets/2026-cms-interoperability-standards-prior-authorization-drugs-proposed-rule
- CMS. "2026 CMS Interoperability Standards and Prior Authorization for Drugs Proposed Rule." https://www.cms.gov/priorities/burden-reduction/overview/interoperability/policies-regulations/cms-interoperability-standards-prior-authorization-drugs-proposed-rule-cms-0062-p
- MultiState. "Prior Authorization Reform Gains Momentum in States." August 14, 2025. https://www.multistate.us/insider/2025/8/14/prior-authorization-reform-gains-momentum-in-states
- PHSL. "Gold Carding — A New Approach to Improving Prior Authorizations." https://phslrx.com/gold-carding-a-new-approach-to-improving-prior-authorizations
- AMA. "'Gold Card' Approach to Prior Authorization Introduced in Congress." https://www.ama-assn.org/practice-management/prior-authorization/gold-card-approach-prior-authorization-introduced-congress
- NAIC. "Prior Authorization White Paper." December 4, 2025. https://content.naic.org/sites/default/files/inline-files/PA%20white%20paper%2012.4.2025%20final.pdf
- Texas Medical Association. "2025 Legislative Wrap-Up: Gold Card Law Refinements Close Gaps." September 2025. https://www.texmed.org/LegeWrapInsurance
- Rx Almanac. "State Prior Authorization Reform Tracker." https://rxalmanac.com/articles/state-pa-reform-tracker
- AJMC. "State Restrictions on Prior Authorization." 2025;31(9):444-445. https://www.ajmc.com/view/state-restrictions-on-prior-authorization
- Triage Cancer. "Health Insurance State Laws: Prior Authorizations." https://triagecancer.org/state-laws/health-insurance-prior-authorization
