Policy Watch: October 2026
Welcome!
Navitus is pleased to share the October edition of The Beacon: Policy Watch, our monthly update to inform our clients and consultants about legislative and regulatory developments affecting pharmacy benefits. We’re here every month to share thoughts, informed by the Navitus Government Relations and Legal teams. Our goal is to help you stay prepared and ahead of change.
Legislative updates
California
- Effective January 1, 2027: California enacted several laws affecting utilization management and prescription drug coverage. New requirements include:
- Expedited prior authorization reviews for certain rare disease treatments
- Expanded coverage protections for FDA-approved Alzheimer’s treatments
- Restrictions on the use of step therapy for certain memory-related conditions
- Streamlined approval processes for some dosage adjustments involving serious chronic conditions and cancer
- Expanded access requirements for antiretroviral therapies and related products
What it means for you:
California continues to expand patient access protections and place new limits on the use of prior authorization and step therapy. Plans and plan sponsors with California-regulated membership should review utilization management programs and benefit designs for potential compliance and cost implications.
- Effective January 1, 2027: California authorized the state’s Health and Human Services Agency to pursue partnerships aimed at improving affordability and addressing supply challenges for at least one GLP-1 anti-obesity medication.
What it means for you:
As demand for GLP-1 therapies continues to grow, policymakers are exploring new approaches to improve access and affordability. Plans and plan sponsors may see additional state-level activity related to these medications in the coming years.
Delaware
- Effective September 8, 2026:
Delaware enacted legislation expanding pharmacy benefit manager (PBM) reporting requirements and establishing new standards governing pharmacy reimbursement, audits and contract appeals. Beginning in 2027, PBMs generally may not reimburse below certain established drug cost benchmarks.
What it means for you:
Like many other states, Delaware continues to increase oversight of pharmacy reimbursement practices. These changes could influence pharmacy network economics and overall pharmacy benefit costs.
- Effective September 8, 2026:
Delaware now requires state-regulated health plans, including Medicaid, to cover medically necessary menopause services. It also limits the use of prior authorization and step therapy for hormone therapy.
What it means for you:
This legislation reflects a broader trend toward expanding access to condition-specific therapies. Plans and plan sponsors should evaluate benefit designs and utilization management practices to ensure compliance.
- Effective January 1, 2028:
Delaware enacted expanded mental health and substance use disorder coverage requirements, including protections designed to improve access to medications during qualifying emergencies.
What it means for you:
The legislation reflects continued efforts to strengthen behavioral health access and continuity of care. Organizations should monitor implementation requirements as they develop.
Regulatory updates
Delaware
- Effective September 11, 2026:
Delaware implemented a six-month deadline for certain Medicaid retroactive eligibility requests.
What it means for you:
While primarily affecting Medicaid administration, the rule illustrates ongoing efforts by states to establish clearer eligibility and coverage timelines within public programs.
Florida
- Effective September 22, 2026: Florida finalized regulations establishing reimbursement procedures and examination requirements for PBM market conduct investigations. PBMs will continue to be subject to recurring examination cycles.
What it means for you:
States continue to increase oversight of PBMs through audits, examinations and reporting requirements. This trend is expected to continue as policymakers seek greater transparency within the pharmacy benefit marketplace.
New Mexico
- Effective September 1, 2026:
New Mexico updated procedures governing Medicaid audit settlement reconsideration requests.
What it means for you:
The change primarily affects Medicaid program administration but reflects ongoing refinement of state oversight and dispute-resolution processes.
Oregon
- Effective October 1, 2026:
Oregon updated annual prescription drug price reporting requirements for manufacturers.
What it means for you:
States remain focused on prescription drug affordability and pricing transparency. Enhanced reporting requirements may provide additional visibility into drug pricing trends and support future policy initiatives.
Virginia
- Effective September 23, 2026:
Virginia expanded its list of Schedule I controlled substances to include additional fentanyl-related compounds.
What it means for you:
Organizations should continue monitoring evolving controlled substance classifications, which can influence formulary management, utilization oversight and compliance activities.
Guidance
West Virginia
- Issued October 8, 2026:
The West Virginia Offices of the Insurance Commissioner issued guidance stating that group purchasing organizations must be licensed as PBMs if they negotiate drug prices, rebates or administrative fees on behalf of PBMs.
What it means for you:
The guidance reflects ongoing state scrutiny of entities involved in pharmaceutical contracting and rebate arrangements. It may signal continued regulatory attention on transparency and accountability throughout the prescription drug supply chain.
Closing thought
Several themes emerged this month, including continued state efforts to limit utilization management requirements, expanding access to high-cost and specialty therapies, increasing oversight of pharmacy reimbursement practices and growing interest in prescription drug affordability. As states take a more active role in shaping pharmacy benefit policy, plans, plan sponsors and consultants should remain attentive to developments that may influence benefit design, pharmacy costs and member access.
Thank you for reading The Beacon: Policy Watch. We’ll see you next month.
This newsletter is for educational purposes only, and it may not contain all laws enacted throughout the country. It should not be used as a primary source, and it is not legal advice intended to substitute for legal counsel. Please seek appropriate legal or other professional advice before taking any actions related to subject matter discussed here.
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