Cost & Insurance

GLP-1 Open Enrollment 2027: Check Your Plan's Coverage Before You Pick

The plan you choose this fall decides whether Wegovy, Zepbound or Foundayo costs you a copay, a prior authorization fight or the full cash price next year.

October 30, 2026 · 10 min read · Last checked: October 30, 2026

Before you click "enroll" for 2027, open the plan's drug list and its benefits booklet and search for your GLP-1 by name. HealthCare.gov open enrollment starts November 1, 2026, and Medicare's window is already open until December 7. A plan with a lower premium can cost far more if it excludes weight-loss drugs or buries them behind prior authorization.

This guide shows where coverage is won or lost: the formulary, the exclusion list, the prior authorization rules and, for Medicare, the temporary GLP-1 Bridge. It ends with cash-pay options if no plan works.

The 2027 enrollment dates

Deadlines differ by coverage type. Missing one usually means waiting a full year unless you qualify for a special enrollment period.

HealthCare.gov lists the November 1 start, the December 15 cutoff for January 1 coverage and the January 15 close. Medicare.gov confirms the October 15 to December 7 window. Healthcare Insider reports state exchange deadlines such as Idaho's December 15 close and January 31 for California, New Jersey and New York. Check your own state exchange for its exact date.

How to read a formulary for a GLP-1

A formulary is the plan's list of covered prescription drugs. Federal rules require Marketplace plans to post a complete, current list on their public website, including tiers and restrictions, without making you log in.

What to look for

• The exact product. Search for Wegovy, Zepbound, Foundayo, and the pen or vial form you use. Medicare's Bridge, for example, covers Zepbound only in the KwikPen form.
• The tier. Higher tiers usually mean higher copays or coinsurance. Note the dollar figure in the plan's Summary of Benefits.
• Restriction codes. "PA" means prior authorization. "ST" means step therapy, where you try another drug first. "QL" means a quantity limit.
• The covered use. A drug can be listed for diabetes but excluded for weight management. Ozempic and Mounjaro on a list do not mean Wegovy or Zepbound are covered.

Weight-loss exclusions: the clause that decides everything

Prescription drugs are one of the ten essential health benefits every Marketplace plan must cover. HealthCare.gov notes that specific covered services vary with each state's requirements. That is why one plan covers Wegovy for weight loss and the next one does not.

Employer plans are often stricter. KFF's 2026 Employer Health Benefits Survey found that 18% of firms with 200 or more workers cover GLP-1s for weight loss. The share rises to 33% among firms with 5,000 or more workers.

Coverage often comes with conditions. Among covering firms, 40% require enrollees to meet with a dietitian, case manager or therapist, or join a lifestyle program, per KFF.

Where exclusions hide

1. Open the plan's Evidence of Coverage or certificate of coverage, not just the summary.
2. Search the document for "weight loss," "weight management," "obesity" and "anti-obesity."
3. Read the exclusions section and any pharmacy rider separately. They can contradict the drug list.
4. If it is unclear, call the plan and ask: "Is semaglutide or tirzepatide covered for chronic weight management, and with what criteria?" Write down the date, name and reference number.

Prior authorization, exceptions and appeals

HealthCare.gov defines prior authorization as approval from a health plan that may be required before you fill a prescription. For GLP-1s, plans commonly ask for a BMI, related health conditions and proof of a lifestyle program. Ask the plan for its written criteria before you enroll.

If your drug is not on the list

Marketplace plans must offer an exception process for drugs not on the formulary. Under federal rule 45 CFR 156.122, the plan must decide a standard request within 72 hours and an urgent one within 24 hours. If it denies the request, you can ask for review by an independent organization.

If a claim or authorization is denied

HealthCare.gov says you have 180 days from the denial notice to file an internal appeal. For a service you have not received yet, the plan must finish that appeal within 30 days. After that, you can request external review, where the insurer no longer has the final say. Our guide to options after a GLP-1 insurance denial covers the next steps in detail.

Medicare and GLP-1s for 2026 and 2027

By law, Medicare Part D cannot cover drugs used for weight loss, as KFF explains. To work around this, CMS launched a time-limited demonstration called the Medicare GLP-1 Bridge on July 1, 2026.

What the Bridge covers

According to Medicare.gov, the Bridge covers Foundayo tablets, Wegovy injection or tablet, and Zepbound KwikPen. Zepbound single-dose vials and pens are not covered. The copay is $50 per one-month supply.

The program is open to people 18 or older who meet one of three BMI and condition combinations when starting therapy:

• BMI of 35 or higher.
• BMI of 30 or higher, plus diastolic heart failure, uncontrolled high blood pressure or stage 3a or higher chronic kidney disease.
• BMI of 27 or higher, plus prediabetes, a prior heart attack or stroke, or symptomatic peripheral artery disease.

You are not eligible if your Part D plan already covers your GLP-1, or if you have type 2 diabetes, moderate-to-severe sleep apnea or fatty liver disease. In those cases, Medicare.gov says your Part D plan may still cover a GLP-1 for that condition.

What it means for your plan choice

The Bridge runs outside normal Part D payment and works with standalone drug plans, Medicare Advantage plans with drug coverage, Special Needs Plans and employer group plans. Your provider handles prior authorization, and Medicare.gov says that approval covers refills and dose changes through December 31, 2027.

The $50 copay does not count toward your Part D deductible or out-of-pocket limit. Extra Help cannot lower it. So during this open enrollment, choose a drug plan based on your other medications, while making sure you stay in a plan type the Bridge accepts.

CMS originally planned a broader program, the BALANCE Model, for Medicare. CMS now says BALANCE is not launching in Medicare in 2027 and extended the Bridge through December 31, 2027 instead. What happens after that has not been announced.

If you use a GLP-1 for type 2 diabetes or another covered use, check the 2027 Part D formulary as usual. Your plan's cost-sharing applies, and KFF notes it may be higher than $50.

Cash-pay fallbacks if no plan covers you

If every plan you can buy excludes your drug, compare self-pay prices before you assume compounding is your only option.

Two cautions apply. NovoCare states that self-pay spending does not count toward your deductible or out-of-pocket limit. Manufacturer savings cards for insured patients also exclude people on Medicare, Medicaid and other government programs.

Compounded semaglutide and tirzepatide cost less at many programs, but they are a different category. The FDA says compounded GLP-1s are not FDA approved and are not reviewed for safety, effectiveness or quality. It describes them as generally appropriate only when an approved product cannot meet a patient's medical needs. Price is tempting, so screen any program against our GLP-1 provider red flags checklist, and read how $149 brand pills compare with compounded options.

If you keep an HSA or FSA, ask how it treats your purchase. Our HSA and FSA rules for compounded GLP-1s explain what usually qualifies.

A 7-step pre-enrollment checklist

1. Write down your exact drug, form and dose. "Zepbound KwikPen 5 mg" is more useful than "tirzepatide."
2. Shortlist two or three plans on HealthCare.gov, your state exchange, Medicare's Plan Finder or your employer portal.
3. Open each plan's formulary and record the tier and any PA, ST or QL codes for your drug.
4. Search each plan's coverage document for weight-loss and obesity exclusions.
5. Call the plan for its written prior authorization criteria, and save the reference number.
6. Price the full year. Add 12 months of premiums to your expected drug cost-sharing and deductible, then compare that with a year of self-pay.
7. Enroll before the deadline that applies to you, and save screenshots of the formulary entry and plan documents.

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