The Other Switch: Navigating July Insurance and PBM Changes

Jul 1, 2025

The Other Switch: Navigating July Insurance and PBM Changes

By Brianna Pepin

When we think of major insurance shake-ups, January tends to steal the spotlight. It’s the month of deductible resets, new plan rollouts, and what many biologic coordinators call “insurance blizzard season.” But July brings its own version of disruption—and if you’re not looking for it, you might miss it until it hits your workflow.

From pharmacy benefit manager (PBM) transitions to fiscal-year insurance renewals and new interns entering training programs, July is a critical checkpoint in the world of specialty medication access. In this blog, we’ll unpack what makes July a unique challenge, how to prepare for it, and ways to keep patient care moving forward without delays.

Why July Deserves Attention

While most major commercial plan changes are effective in January, some employer-sponsored plans operate on a fiscal year, with benefits resetting or changing in July. Additionally, this is the time many hospitals onboard interns and residents who are new to navigating specialty medications, prior authorizations, and copay assistance.

PBMs also sometimes switch mid-year—quietly. For example, a plan may move from OptumRx to Express Scripts, or from CVS Caremark to MedImpact, affecting not just processing but which specialty pharmacies are in-network.

As biologic coordinators, this means:

Rejected prescriptions with unfamiliar rejection codes
Delayed shipments from specialty pharmacies
New or changing copay assistance requirements
Coverage gaps for patients mid-treatment

What Changes to Watch For

Here are some common shifts we start to see in late June and early July:

1. PBM Changes

Employers sometimes change PBMs mid-year without much fanfare. This can affect:

Where the medication is sent (specialty pharmacy network)
Processing time for PAs
Copay card compatibility

2. Plan Resets or Renewals

Fiscal-year plans may:

Restart deductibles
Shift tier placement of biologics
Require new prior authorizations or step edits

3. New Prescribers and Interns

In academic institutions, new prescribers may not yet understand:

The time-sensitive nature of biologics
How to initiate PAs or copay card enrollment
The importance of timing re-enrollment for bridge programs

Best Practices for July Readiness

Here’s how to prepare your team and processes for the mid-year switch:

Run a July “Benefits Recheck”
For all commercial patients, especially those with employer-sponsored plans, recheck benefits in late June or early July to catch any PBM or plan changes.
Flag High-Risk Plans
Keep a list of plans you’ve seen switch in July in past years. Some self-funded employers consistently flip during this time.
Watch for Red Flags
Be on alert for:
- Rejections that say "plan not found" or “not covered”
- Sudden requests for new PAs or different pharmacy routing
- Copay cards that no longer process
Communicate with Specialty Pharmacies
Specialty pharmacies often detect PBM changes before you do. If a shipment is delayed, call to ask if there was a benefit update or plan switch.
Educate Interns and Providers
Take a few minutes in July to explain the role of a biologic coordinator to new providers. Offer a quick orientation on your PA and support workflows—they’ll appreciate it more than you think.

Supporting Patients Through the Transition

Changes in coverage can be frustrating for patients—especially if they’ve finally found a treatment that works. Be proactive:

Let them know July is a time of possible plan changes
Encourage them to notify you if they receive new insurance cards
Re-enroll them in copay or manufacturer support programs as needed
Set realistic expectations about possible delays and reassure them you’re monitoring things closely

Final Thoughts: Stay Ahead of the July Wave

July might not be as hectic as January, but it brings a different kind of challenge—quieter, but no less disruptive. With a little preparation, biologic coordinators can stay a step ahead of mid-year plan changes and ensure a smooth summer for patients and providers alike.

If you're tracking July plan or PBM changes in your region, consider sharing them with your network—it helps us all stay prepared.

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At BC Educators, we are dedicated to empowering biologic coordinators, healthcare professionals, and patient advocates with the education, tools, and resources needed to optimize patient care. From expert-led webinars to hands-on training, we provide comprehensive support to help you navigate the ever-evolving landscape of specialty medications and prior authorizations.