The pharmacy landscape in 2026 will be defined by rapid innovation, regulatory shifts and evolving cost pressures. Plan sponsors face a pivotal year as specialty drug launches, biosimilar expansion and policy changes reshape formulary strategy and contracting. Here's what you need to know — and why it matters.
Market outlook
- Expect significant disruption in drug pricing, access and regulatory pricing. High-cost specialty therapies and expanded biosimilar availability will challenge traditional utilization management.
- Managing high-spend therapeutic classes, particularly GLP-1 receptor agonists, will remain a challenge, especially given their recently expanded indications for obesity-related conditions, which are expected to drive further utilization and cost pressure.
- Impactful drug approvals in ophthalmology, endocrinology, neurology and pulmonary spaces are anticipated in 2026, along with key generic and biosimilar launches. These approvals may significantly affect pharmacy spend and/or require changes to formulary and utilization management strategies.
Reservation of Rights
Pharmacy benefit managers (PBMs) may update contract language to allow pricing adjustments based on market conditions or utilization trends. These provisions could enable changes to drug or therapeutic class pricing if actual utilization differs from underwriting forecasts. Even minor amendments may include revised Reservation of Rights (ROR) language, making thorough review critical.
Top 10 trends to watch
1. Medicare drug price negotiation
- Maximum Fair Price (MFP) is effective January 2026 for 10 Part D drugs: Januvia, Jardiance, NovoLog/Fiasp, Farxiga, Eliquis, Xarelto, Entresto, Imbruvica, Enbrel and Stelara.
- An additional 15 drugs have been announced for 2027, including popular drugs such as Ozempic, Janumet and Tradjenta.
- Commercial payers may adjust formularies if rebates shift or manufacturers cut Wholesale Acquisition Cost (WAC) in response to MFP.
2. Most-Favored-Nation Agreements and Medicaid pricing
- Executive order requires most-favored nation (MFN) pricing for Medicaid beneficiaries; five manufacturers have agreed — Pfizer, AstraZeneca, EMD Serono, Novo Nordisk and Eli Lilly.
- MFN guarantees that future US drug prices won't exceed global prices. The significance of this requirement is still unclear.
3. Direct-to-consumer and TrumpRx
- TrumpRx.gov launched in January 2026 to connect patients to manufacturer direct-to-consumer (DTC) platforms.
- GLP-1 drugs dominate DTC programs — about one-third of new Zepbound scripts come via LillyDirect.
- Traditional health insurance might still be the most economical option; any out-of-pocket cost-sharing will count toward deductible and annual out-of-pocket maximum.
- In 2026, Eli Lilly will introduce an employer-focused model for obesity care, offering flexible benefit design, a transparent pharmacy network and customized holistic programs including clinical care, behavior-change support and virtual or in-person services.
4. Biomarkers and gene therapy expansion
- Precision medicine moves beyond oncology into neurology, cardiology and rare diseases.
- Key pipeline includes: Lp(a)-targeted siRNA (Lilly, Amgen), LGMD2E gene therapy (Sarepta) and mucopolysaccharidosis II central nervous system (CNS) gene therapy (Regenxbio).
5. 340B rebate model pilot
The pilot, which launched in January 2026 for Medicare Drug Price Negotiated drugs, shifts from upfront discounts to a rebate-based model, increasing administration burden but improving transparency.
6. FDA biosimilar guidance changes
Streamlining the approval process, the Food and Drug Administration (FDA) proposes all biosimilars are deemed interchangeable, enabling automatic substitution.
7. PBM reform
- Federal action is stalled; a new bipartisan bill was introduced December 2025 for transparency and rebate pass-through.
- States intensify PBM oversight, including ownership bans, licensure and transparency requirements.
8. Biosimilar launches
- For asthma medication Xolair (omalizumab), the first asthma biologic biosimilars are launching (Omlyclo, ADL-018).
- Six biosimilars for Eylea (aflibercept) are expected in the second half of 2026; the price impact delayed due to shift to longer-acting vascular endothelial growth factor (VEGF) inhibitors.
9. First-time generic launches
- Major loss of exclusivity (LOEs) agents include Januvia/Janumet, Xeljanz, Pomalyst, Ofev, Opsumit, Uptravi and Trintellix.
- The savings potential is significant; for example, Januvia has ~$8.5B in US sales.
10. Therapeutic areas to watch
- Ophthalmology: Gene therapies for retinitis pigmentosa, Leber congenital amaurosis
- Endocrinology: Gene therapies for MPS II and III; novel emotional response therapies (ERTs)
- Neurology: First drug for obstructive sleep apnea; spinal muscular atrophy (SMA) therapies
- Pulmonary: Jascayd approved for idiopathic pulmonary fibrosis (IPF); the cost is high (~$200K/year)
To learn more about navigating these complicated topics, contact your Gallagher consultant or Gallagher's Pharmacy and Health Plan Services.
