Why 2026 Is Different
Every year, insurers update their formularies, prior authorization rules, and provider networks. But 2026 brings an unusually large wave of changes that could affect millions of Americans.
⚠ Enhanced ACA Subsidies Set to Expire
The enhanced premium tax credits from the American Rescue Plan and Inflation Reduction Act are scheduled to expire at the end of 2025. Without Congressional action, average monthly premiums for ACA marketplace plans could rise by more than 75% in 2026.
Source: Kaiser Family Foundation
Formulary Changes
Insurance companies typically finalize 2026 drug lists in the fall of 2025. Medications you rely on may move to higher cost tiers—or be removed entirely.
Prior Authorization Tightening
Insurers are adding more procedures and medications to prior authorization lists, which means more hoops to jump through before care is approved.
Areas to Watch in 2026
These categories have historically seen the most coverage changes during annual updates.
GLP-1 receptor agonists have faced increasing restrictions as their popularity—and costs—have surged. Many insurers are:
- Requiring step therapy (trying older, cheaper medications first)
- Adding stricter BMI or A1C requirements
- Distinguishing between diabetes treatment and weight management coverage
- Implementing quantity limits or requiring periodic re-authorization
What to do: If you're currently on a GLP-1, ask your provider about documentation strategies and check your plan's 2026 formulary as soon as it's available.
Biologics for conditions like rheumatoid arthritis, psoriasis, Crohn's disease, and multiple sclerosis often face coverage changes as biosimilars enter the market. Watch for:
- Mandatory switches from brand-name biologics to biosimilars
- New prior authorization requirements
- Changes to specialty pharmacy requirements
- Revised step therapy protocols
What to do: Talk to your specialist about any biosimilar switches and ensure your medical records document why your current medication is necessary.
Despite mental health parity laws, coverage for psychiatric medications varies significantly. Common issues include:
- Step therapy requirements for newer antidepressants or mood stabilizers
- Prior authorization for ADHD medications
- Quantity limits on controlled substances
- Network restrictions for prescribing providers
What to do: If you're stable on a medication, document your treatment history. Mental health parity laws may support your appeal if denied.
Coverage for gender-affirming care varies widely by state and plan type. Be prepared for:
- New exclusions or limitations in some plans
- Increased documentation requirements
- Prior authorization for hormone therapy
- Network limitations for specialized providers
What to do: Review your plan documents carefully during open enrollment. Some states have protections that override plan exclusions—know your rights. See our guide on federal protections.
CPAP machines, wheelchairs, prosthetics, and other DME often face coverage challenges:
- Stricter medical necessity documentation
- Rental vs. purchase requirements
- Limited in-network suppliers
- Replacement and repair restrictions
What to do: Get equipment needs documented before year-end. If you need replacement items, start the authorization process early.
2026 HSA & FSA Updates
The IRS typically announces new HSA contribution limits in the spring. New 2026 limits are:
- Individual: $4,400
- Family: $8,750
- Catch-up (55+): Additional $1,000
FSA limits are also adjusted annually. Key considerations:
- Use-it-or-lose-it rules (check if your plan has rollover)
- Grace period availability
- Dependent care FSA limits
Prior Authorization: Getting Ahead
Prior authorization requirements are expanding. Here's a checklist to discuss with your providers before January:
Questions to Ask Your Provider
December Action Checklist
Take these steps before the end of 2025 to minimize disruption in 2026.
1 Refill Your Prescriptions
Get a 90-day supply of maintenance medications before December 31 if possible (may require a mail-order fill). If your medication is moving to a higher tier or being removed, you'll want a buffer while appealing or finding alternatives.
2 Download Your 2026 Formulary
Some insurers publish 2026 formularies in October or November. Download a copy and check coverage for your medications. Look for tier placement, prior auth requirements, and quantity limits.
3 Verify Your Providers Are In-Network
Network changes happen frequently, but it's a good time to confirm your doctors, specialists, and facilities will remain in-network. If not, ask about continuity-of-care provisions.
4 Update Your Marketplace Information
If you're on an ACA marketplace plan, update your income estimate and contact information. This ensures you receive any subsidy updates and renewal notices.
5Track your work and school time for Medicare patients
Be ready for the new medicare work requirements
6 Use Your FSA Balance
Most FSA funds have a time limit. Schedule any end-of-year appointments, order glasses or contacts, or stock up on eligible supplies before losing those dollars.
7 Gather Documentation
Collect medical records, letters of medical necessity, and treatment histories. Having this ready makes appeals faster if you face a denial in January.
Your Rights When Denied
If you receive a denial in 2026, remember: you have the right to appeal. Here's what you need to know.
You Can Appeal
Federal law requires insurers to provide at least one level of internal appeal. Many plans often have two. External review by an independent party is also available, often requiring you to exhaust internal options.
Deadlines Matter
Acting quickly is important! Expedited appeals for urgent situations can be decided within 72 hours.
Appeals Work
Studies show that a significant percentage of appeals are successful. A well-documented appeal with supporting medical evidence increases your chances.
Ready to Fight a Denial?
Our AI-powered tool helps you generate appeal letters in minutes. Free for everyone.
Generate an Appeal Chat with AI AssistantWhat We Don't Know Yet
We believe in being upfront about uncertainty. Here's what's still unclear as of late 2025:
- ACA Subsidy Extension: Congress may or may not extend enhanced premium tax credits (although time is running out). This could significantly impact marketplace plan costs.
- Individual Insurer Decisions: Each insurer makes their own formulary and prior auth decisions. We can identify patterns, but your specific plan may differ.
- State-Level Changes: Insurance regulations vary by state and are subject to change. Some states are adding protections while others are reducing them.
- Medicare Part D Redesign: Ongoing changes to Medicare drug coverage may affect how commercial insurers structure their own plans.
- Employer Plan Changes: If you get insurance through work, your employer's decisions about plan design aren't known until open enrollment.
Additional Resources
Stay Informed, Stay Prepared
The best time to prepare for coverage changes is before they affect you. Bookmark this page, talk to your providers, and know that help is available if you need to appeal a denial.
Disclaimer: This page is for informational purposes only and does not constitute legal, medical, or financial advice. Insurance policies vary widely, and you should review your specific plan documents for accurate information about your coverage. Information about 2026 changes is based on publicly available data and may change as insurers and regulators finalize decisions. Last updated: December 2025.