These categories matter in compliance: These go through Phases I-III clinical trials, get reviewed, and are approved for specific indications and doses
These actions enhance cell proliferation and migration, promote new blood vessel formation ( angiogenesis ), and accelerate wound closure in injured tissues
Already in effect (January 1, 2026): Standard PA decisions within 7 calendar days (down from 14) Urgent PA decisions within 72 hours Specific denial reasons required on every denial (not just not medically necessary) Applies to Medicare Advantage, Medicaid managed care, CHIP, and ACA Marketplace plans Coming March 31, 2026: Payers must publicly report PA metrics for calendar year 2025: approval/denial rates, average decision times, and appeals outcomes Providers will be able to compare payer performance for the first time Coming January 1, 2027: FHIR-based Prior Authorization APIs required providers check PA requirements, submit requests, and receive decisions electronically through their EHR Expected to reduce average PA processing time from days to minutes for standard requests Medicare WISeR Model (live in AZ and WA): The Wasteful and Inappropriate Services Reduction pilot launched January 2026 in six states including Arizona and Washington
If youre dealing with Crohns disease, IBD, or other GI conditions: Talk with a clinician about evidence-based options first, which may include medications like mesalamine or budesonide as well as new lifestyle and dietary approaches
Medicare does not cover Zepbound for weight loss
