GLP-1 Coverage at Open Enrollment 2027: 10 Questions to Ask

If you take a GLP-1, the best open enrollment move is to check each 2027 plan for your exact medicine, for your reason for taking it, then add up the whole year's cost: premiums, deductible and pharmacy cost-sharing. A plan with a lower premium can easily cost more by March. Below are 10 questions to ask, the 2027 deadlines, and a comparison sheet you can fill in.

Think of it as a shopping list for a decision you'll live with for twelve months.

When is open enrollment for 2027 plans?

Coverage type	2027 open enrollment
Medicare (Part D and Medicare Advantage)	October 15 – December 7, 2026; coverage starts January 1
HealthCare.gov Marketplace	November 1, 2026 – January 15, 2027; enroll by December 15 for a January 1 start
State-run Marketplaces	Check your state's site; dates can differ
Employer plans	Set by your employer, often a few weeks in the fall

Miss the window and you generally wait a year, unless a life event opens a special enrollment period.

The 10 questions to ask about GLP-1 coverage

1. Is my exact medicine on the 2027 formulary?

Search the plan's 2027 drug list, not this year's. Look for the brand and the form: a Zepbound KwikPen and Zepbound vials can be listed differently, and so can Wegovy pens and tablets. Our guide to reading a formulary shows where the tier and restriction codes hide.

2. Is it covered for weight management, or only for something else?

This is the question that catches people. Many plans cover GLP-1s for type 2 diabetes but exclude them for weight management. A drug on the formulary isn't proof it's covered for your reason. Check the plan's exclusions list and ask directly: "Is this drug covered for chronic weight management?"

3. Does it need prior authorization, and what are the criteria?

Ask for the written criteria: BMI cutoffs, qualifying conditions, required chart notes, how long an approval lasts and what renewal requires. If you're already on treatment, ask whether a new plan would ask for your starting weight or your current one. That matters if you've lost weight.

4. Is there a lifestyle-program or clinical-visit requirement?

More plans add these. KFF's 2026 employer survey found that 40% of employers covering GLP-1s for weight loss require meetings with a dietitian, case manager or therapist, or a lifestyle program. Find out what counts, who provides it and whether it costs extra. More in when a plan requires a lifestyle program.

5. Is there step therapy or a preferred brand?

Some plans require trying a preferred product first, or cover only one brand in the class. If you're stable on one medicine, ask whether switching would be required.

6. Are there quantity limits or dose restrictions?

Ask whether higher doses (or newer high-dose versions) are covered the same way as starting doses, and whether there's a monthly quantity limit.

7. Which pharmacy do I have to use?

Some plans send certain drugs to a specialty or mail-order pharmacy only. KFF found that 11% of employers with 50+ workers limit coverage for certain prescriptions to mail-order pharmacies. If your plan does that, the corner pharmacy won't be paid.

8. What will I actually pay at each point in the year?

Ask what you'd pay before the deductible is met and after, and whether the drug has a flat copay or a percentage coinsurance. Coinsurance is charged on the plan's negotiated price, which you usually can't see, so ask for an estimate. For the full walkthrough, see covered vs affordable.

9. Can the plan change coverage in the middle of 2027?

Plans generally update their documents at renewal. For job-based plans, if a mid-year change would affect what your Summary of Benefits and Coverage says, federal rules require notice at least 60 days before it takes effect. Ask how the plan announces formulary changes and how you'd be told.

10. If I use a manufacturer savings card, does it count toward my deductible?

Some plans don't credit manufacturer card payments toward your deductible or out-of-pocket maximum. The cards also have limits. For example, Lilly's Zepbound savings card terms cap savings per month and per year and exclude anyone on Medicare, Medicaid or other government coverage. Ask the plan, and read the card's terms.

How do I compare the total yearly cost of a plan?

Here's the formula, then a sheet to fill in:

Yearly cost ≈ (monthly premium × 12) + what you'll pay for the drug over 12 fills + expected visit and lab cost-sharing

The drug piece is where plans differ most. In a plan with a deductible, early fills may cost the full negotiated price until the deductible is met. After that, you pay the copay or coinsurance until you hit the out-of-pocket maximum. For 2027, the federal cap for in-network covered costs in ACA-compliant plans is $12,000 for one person and $24,000 for a family. Many plans set lower caps. Premiums, excluded drugs and out-of-network care don't count toward it.

Side-by-side sheet (copy this):

Question	Plan A	Plan B	Plan C
Monthly premium
Deductible (does it apply to drugs?)
My drug and form on the 2027 formulary? Tier?
Covered for weight management?
Prior authorization criteria
Lifestyle program required?
Required pharmacy
Cost per fill before / after deductible
Out-of-pocket maximum
My prescriber in network?
Estimated total for 2027

Where to find the answers in writing

• Summary of Benefits and Coverage (SBC). Every job-based plan and insurer has to provide one at application and renewal, and on request. It's a standard format, so plans are easy to compare.
• The 2027 formulary and the plan's coverage policy or prior authorization criteria for your drug.
• Summary Plan Description for employer plans; ask HR.
• Medicare Plan Finder on Medicare.gov for Part D and Medicare Advantage.

If you're on Medicare and using or planning to use the GLP-1 Bridge, also check that your 2027 plan type still qualifies. Our Bridge eligibility checklist lists which plan types count.

A note on your records

When you call a plan, write down the date, the representative's name and a reference number. A promise made on the phone is hard to prove later. It also helps to have your own treatment timeline handy (start date, current dose, weight history). GLPily keeps your shot or pill log and weight history together, so those answers are a few taps away.

And if your job-based plan is the one changing, our piece on why employer coverage varies explains what's going on behind the scenes.

Common questions

Can I switch plans mid-year if my GLP-1 coverage changes?

Usually not just because one drug's coverage changed. Mid-year changes generally need a qualifying life event or a special enrollment period, so open enrollment is the main chance to choose.

Does a drug on the formulary mean it's covered for weight loss?

Not always. A plan can list a GLP-1 for diabetes and still exclude it for weight management. Check the exclusions and the prior authorization criteria.

What's the most I can pay out of pocket in 2027?

For ACA-compliant plans, the 2027 in-network limit is $12,000 for an individual and $24,000 for a family. Your plan may set a lower number. Premiums and non-covered drugs don't count toward it.

When is Medicare open enrollment for 2027?

October 15 to December 7, 2026, with coverage starting January 1, 2027.