7 Common Medications Affected by Midyear Pricing Shifts

common medication pricing shifts — Image Source: Shutterstock

We are trained to expect changes to our health insurance in January. We spend December reviewing Open Enrollment packets, selecting a plan, and budgeting for the new year. However, for millions of Americans, the most disruptive changes actually happen in the summer. July 1st marks the start of the fiscal year for many employer-sponsored health plans and a major update cycle for Pharmacy Benefit Managers (PBMs).

In 2026, this “midyear shuffle” is particularly aggressive. Insurers are scrambling to manage the high costs of weight loss drugs and biologics. As a result, medications that were covered in January might be excluded in July. If your employer’s plan renews this summer, or if your PBM updates its exclusion list, you could face sudden sticker shock. Here are the seven medications most likely to see pricing or coverage shifts right now.

The GLP-1 Weight Loss Block (Wegovy/Zepbound)

The most significant midyear change for 2026 involves the popular class of weight loss drugs. While many plans dropped coverage in January, a second wave of exclusions is hitting with July 1st plan renewals. Major insurers like Blue Cross Blue Shield have announced that GLP-1s for weight loss (specifically Wegovy, Saxenda, and Zepbound) will be excluded upon plan renewal.

For many employees, that renewal date is July 1st. If you have been paying a standard copay for these drugs, you might suddenly be responsible for the full $1,000+ monthly cost. This does not typically affect those taking Ozempic or Mounjaro for Type 2 Diabetes, but “off-label” use is being audited strictly.

The Humira Biosimilar Forced Switch

For years, Humira was the world’s best-selling drug, but 2026 is the year it effectively disappears from many formularies. The “Big Three” PBMs (CVS Caremark, Express Scripts, and Optum Rx) have aggressively moved to exclude the brand-name drug in favor of lower-cost biosimilars like Hadlima or private-label versions like Cordavis.

While some plans made this switch in January, others are rolling it out midyear to allow for a “transition period.” If you are still taking brand-name Humira, expect a letter forcing you to switch to a biosimilar to keep your coverage. The copay should be lower, but the disruption to your routine is real.

The Palforzia Discontinuation

For families managing severe peanut allergies, a major shock is arriving this summer. Stallergenes Greer, the manufacturer of Palforzia, has announced it will discontinue the drug effective July 31, 2026. This is not a coverage change; it is a total market exit.

If you or your child is currently undergoing oral immunotherapy with this product, you must speak to your allergist immediately. You cannot start a new treatment cycle that won’t finish before the July cutoff. You need a transition plan to alternative therapies before the supply runs dry.

The Stelara “Non-Preferred” Demotion

Following in Humira’s footsteps, Stelara (used for Crohn’s and colitis) is facing stiff competition from new biosimilars in 2026. Many insurers are moving brand-name Stelara to a “non-preferred” tier or excluding it entirely in favor of biosimilars like Wezlana.

This shift often bumps your copay from a flat fee (e.g., $45) to a coinsurance percentage (e.g., 30% of the cost). For a drug that costs thousands of dollars, this pricing shift can be devastating. Check your plan’s July formulary update to see if Stelara has been moved to a higher tier.

The Asthma Inhaler Shuffle

The fallout from the discontinuation of Flovent continues to cause confusion in 2026. Insurers are constantly shuffling preference between authorized generics and alternative brands like Arnuity or Qvar. Because the authorized generic of Flovent is not always covered, patients are often forced to switch inhalers mid-year.

If your pharmacy suddenly tells you your “generic Flovent” isn’t covered, it’s likely a formulary preference change. You may need a new prescription for a completely different inhaler brand to avoid paying the full cash price.

The Insulin Brand Swap

While the $35 monthly cap on insulin is federal law for Medicare (and many state plans), it only applies to covered insulins. Plans often swap their “preferred” insulin brands midyear to chase deeper rebates. Your plan might switch from covering Lantus to covering Basaglar or Semglee.

If you refill your old brand, the $35 cap will not apply, and you will be charged the full list price. You must use the specific insulin brand on the formulary to trigger the price protection. Watch your mail for “Change of Coverage” notices regarding your insulin brand.

The “Negotiated 10” Utilization Management

Medicare negotiated lower prices for ten blockbuster drugs (including Eliquis, Jardiance, and Xarelto) effective January 1, 2026. However, to recoup some of those “losses,” some plans are tightening utilization rules midyear.

You might face new “Step Therapy” requirements where you must try a cheaper drug before the negotiated drug is approved. Even though the price is lower, the access might be harder. If your refill is denied in July, it is likely a new prior authorization hurdle you need to clear.

Stay Vigilant

Insurance is not a “set it and forget it” product. The rules that applied in January may not apply in July. Open every letter from your insurance company this month—it might be the warning you need to avoid a $500 mistake at the pharmacy counter.

Did your employer drop weight loss drug coverage this month? Leave a comment below—tell us how you are managing!