Prior Authorization Reform: 2026 Changes to Improve Patient Access

What changes are being prioritized for prior authorization in 2026? States are focusing on reforming prior authorization processes to better balance patient access concerns with insurers’ utilization management strategies, which are aimed at controlling costs. Continuous glucose monitors illustrate the complexities of this issue, as many covered devices require prior authorization, and coverage criteria often conflict with current diabetes care standards. Patients and providers face challenges due to coverage rules that are frequently hidden outside formularies, complicating device access before treatment decisions are made. Early access to devices can be critical, enabling individuals to adjust insulin levels, prevent dangerous blood sugar fluctuations, and ultimately lower emergency and hospitalization costs. Proposed reforms include enhancing transparency, expediting decision-making, implementing evidence-based criteria, limiting delays, and conducting expert clinical reviews during appeals for disputed care requests.

Understanding these reform efforts is essential for anyone navigating the healthcare landscape, as they hold significant implications for patient care and access to necessary treatments.

For expert guidance on insurance and protecting what matters most, connect with Guljinder Singh, insurance advisor at Insurance and Investment Solutions.