Gold Carding: The Prior Auth Exception Most Physicians Don't Know They Can Get
Gold Carding: The Prior Auth Exception Most Physicians Don't Know They Can Get
Audience: Physicians, PA coordinators
Published: 2026-04-01
Category: Practice Management, Prior Authorization
Gold Carding: The Prior Auth Exception Most Physicians Don't Know They Can Get
7 minute read
If your prior authorization approval rate for a specific drug or drug class runs consistently at 90 percent or higher, you may qualify to have that prior authorization requirement removed entirely. The mechanism is called gold carding, and while it has been gaining legislative traction in states across the country since 2021, it remains underutilized by the physicians who could benefit most from it.
This piece explains what gold carding is, which states have passed laws requiring it, how the qualification criteria work, and what steps physicians can take to pursue gold carding status with their high-volume payers.
What Is Gold Carding?
Gold carding is a designation under which an insurer grants a physician or practice an exemption from prior authorization requirements for specific drugs, drug classes, or services. Rather than submitting a PA request each time a qualifying patient needs an authorization, a gold-carded physician can prescribe directly without the authorization step, for the duration of the gold card period.
The rationale is straightforward. If a physician has submitted 40 prior authorization requests for a particular biologic over the past year, and 38 of those requests were approved, the authorization process is generating two legitimate denials and 38 instances of redundant paperwork. Gold carding removes the paperwork for the 38 while preserving the insurer's ability to review the two. In theory, it is a win for both sides.
In practice, gold carding has been slow to diffuse because many payers have not adopted it voluntarily, and because physicians often do not know it is available to request. Legislative mandates in a growing number of states have changed the calculation by requiring payers to offer gold carding to qualifying physicians.
Which States Have Gold Carding Laws?
Gold carding legislation has moved quickly since Texas passed the first statewide gold carding requirement in 2021. As of 2025, the following states have enacted laws or adopted regulations that require commercial insurers to offer prior authorization exemptions to qualifying physicians:
Texas (2021): The original gold carding law. Insurers must offer a prior authorization exemption to physicians who have a 90 percent or higher PA approval rate over a 6-month period for a specific drug, device, or service. The exemption applies to that specific item and is valid for two years.¹
Arizona (2022): Similar structure to Texas. Requires insurers to grant exemptions based on demonstrated approval history.²
Michigan (2022): Gold carding provisions included in broader PA reform legislation. Applies to commercial plans regulated by the state.³
West Virginia (2023): Extended gold carding requirements to Medicaid managed care plans in addition to commercial plans.⁴
Louisiana (2023): Enacted gold carding requirements with physician approval thresholds similar to Texas.⁵
Indiana, South Carolina, and Tennessee have enacted or are actively implementing similar provisions as of 2025.⁶
Limitations by plan type:
Gold carding laws generally apply to state-regulated commercial plans. They do not apply to self-funded employer plans governed by ERISA, which are regulated by the federal Department of Labor rather than state insurance commissioners. Medicare Advantage plans are governed by CMS regulations, which do not yet include a gold carding mandate. Physicians whose patient population skews heavily toward self-funded employer plans or Medicare Advantage may find that state gold carding laws cover a smaller portion of their practice than the headline suggests.
Federal gold carding legislation has been introduced repeatedly in Congress, including as a provision of the Improving Seniors' Timely Access to Care Act, but a comprehensive federal requirement has not yet been enacted.
How the Qualification Criteria Work
Gold carding eligibility is typically based on two measurements: approval rate and minimum volume.
Approval rate threshold: Most state laws set the threshold at 90 percent or higher. That means 9 of 10, or higher, of a physician's PA requests for a specific drug or service must have been approved over the qualifying period. Some payer implementations require the threshold to be met over a 6-month window; others use a 12-month lookback period.
Minimum volume: Many payer implementations require a minimum number of PA submissions before the approval rate is evaluated. A physician who submitted two PAs for a specific drug and had both approved does not qualify because the sample is too small. Typical minimums range from 10 to 25 submissions over the qualifying period, though this varies by payer.
Specificity: Gold carding is drug-specific or service-specific, not a general exemption. A rheumatologist who qualifies for a gold card for Humira does not automatically qualify for one for Rinvoq or Stelara. Each drug or drug class must be qualified separately.
Duration: In most state frameworks, gold card exemptions are valid for one to two years, after which they are subject to renewal based on continued performance.
How to Pursue Gold Carding
Step 1: Identify your high-approval-rate PA categories.
Review your prior authorization history for the past 12 months, by drug and payer. PA coordinators with organized tracking systems can typically pull this analysis quickly. You are looking for drug-payer combinations where your approval rate is 90 percent or higher over a meaningful volume of submissions. These are your gold carding candidates.
Step 2: Confirm whether the payer is subject to a gold carding requirement in your state.
If you practice in a state with a gold carding law, confirm whether the specific payer is subject to it. State-regulated commercial plans are covered; self-funded ERISA plans and Medicare Advantage plans typically are not. Your state insurance commissioner's website should list regulated plans and their compliance with PA reform requirements.
Step 3: Request gold card evaluation from the payer.
Under most state laws, the payer is required to evaluate a physician's eligibility when requested. Contact the payer's provider relations department, reference the specific state statute, and request a review of your PA approval history for the qualifying drug or service. Document your request in writing.
Step 4: Submit supporting documentation.
Some payers require you to submit evidence of your approval rate. Your PA tracking system, combined with the payer's own records, should provide the necessary data. If your payer uses an electronic PA portal that generates approval history reports, this is the place to pull that data.
Step 5: Follow up and track the timeline.
State laws typically specify a timeline within which payers must respond to gold carding requests. If the payer does not respond within the specified window, you have grounds to escalate to the state insurance commissioner.
The Practical Impact on a Practice
For a physician submitting 40 to 50 prior authorizations per week for specialty medications, qualifying for gold card status with even two or three of the most common payer-drug combinations can meaningfully reduce weekly PA burden.
Consider a rheumatologist whose patient panel includes a high proportion of patients on Humira biosimilars through a regional BCBS plan, with a 92 percent approval rate over the past year. If that practice sees 15 Humira-related PAs per month from that payer, a gold card covering those submissions eliminates approximately 180 PA submissions per year. At the AMA's estimated 20 to 30 minutes per PA submission and follow-up, that represents 60 to 90 hours of staff and physician time annually.
That calculation does not account for denials that would have occurred at a 92 percent approval rate (roughly 14 per year in this example), which would themselves require appeals. The gold card eliminates the denial cycle entirely for that payer-drug combination.
What Ellen Can Help With
Ellen's payer intelligence database includes information on state prior authorization reform requirements and gold carding provisions. If you are pursuing gold card status with a specific payer and need to know whether your state's law applies to that plan, or need to draft a formal gold carding request, Ellen can help you identify the relevant statutory language and structure the request.
For practices that are not yet at gold carding volume, Ellen addresses the submission quality side of the problem: building initial LMNs that are specific to payer criteria to increase first-submission approval rates, which is the foundation of eventually qualifying for gold card status.
Learn more at ellenrx.com/providers.
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