On September 2, 2025, the Department of Health and Human Services (HHS) published a final rule to enable better real-time cost-sharing of prescription drug benefits and speed up the process of securing prior authorizations for medications. The rules will modernize electronic prescribing, allow real-time prescription benefit checks (which show the drug cost for the insured patient at various pharmacies and what they could pay for alternative medications), and streamline prior authorization with modern API technology.
Applies To:
Group health plans providing prescription drug coverage.
Go Deeper:
The Consolidated Appropriations Act, 2021 (CAA-21) introduced several price transparency requirements for group health plans. These include real-time cost-sharing so patients and providers can see the types of services or prescriptions the plan will cover, the cost, with considerations for deductibles, copays, and other cost-sharing requirements, and how much the person and family spent toward those requirements so far.
This final rule seeks to enhance the ability of patients and providers to electronically submit a proposed prescription to the plan for real-time verification of whether it is covered, obtain prior authorization quickly using an interactive real-time interface, and determine the various cost options for the desired drug and alternative drugs covered at various pharmacies.
The rule’s requirements to adopt these new technology standards take effect October 1st , and the rule provides a transition period through 2027 for all plans and providers to utilize these new standards. Real-time verification, approval, and cost-sharing is a vital component of the CAA-21 requirements for health plans. In addition, a major milestone of accomplishing the CAA-21 goal is to facilitate prescription drug benefits so patients know their coverage approval, options, and costs before they leave the doctor’s office.
Practical Impact to Employers:
To comply with CAA-21 requirements, carriers and other claims payers for group health plans should implement these new technology standards promptly and over the next two years to provide real-time coverage verification and cost-sharing estimates. Once they integrate such technology into their systems, it is ideal and extremely beneficial to notify plan participants of the opportunity to utilize this new feature of the health plan when they see their health care provider and need a prescribed medication.
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