Medicare and Oral GLP-1s: What to Check During Open Enrollment (Ends Dec 7)

The dates that matter

Sources: Medicare.gov; CMS; KOLD/Gray News, Oct. 15, 2026; Managed Healthcare Executive, Nov. 26, 2025.

The rule underneath everything

By law, Medicare Part D can't cover drugs used specifically for weight loss. KFF's May 2026 explainer says Part D covers GLP-1 drugs only for other FDA-approved, medically accepted uses, such as type 2 diabetes, cardiovascular risk reduction or sleep apnea.

That rule hasn't changed. What changed in 2026 is a temporary program that runs alongside Part D for weight management. In practice, your 2027 GLP-1 coverage depends on why the drug is prescribed:

The Medicare GLP-1 Bridge

CMS's Bridge demonstration started July 1, 2026, and was extended to run through December 31, 2027. Here's what Medicare.gov and CMS say about it.

Which drugs

Foundayo (tablet), Wegovy (tablet or injection), and Zepbound in the KwikPen version only. Two of the three are oral: the Wegovy pill and Foundayo. Rybelsus and Ozempic tablets aren't on the list. They're type 2 diabetes drugs and go through Part D (Route 2).

Who's eligible

• You must have Medicare drug coverage: a standalone Part D plan, a Medicare Advantage plan with drug coverage, a Special Needs Plan, an employer or union group plan, or the LI NET program.
• You must be 18 or older.
• When you started GLP-1 therapy, you must have met one of these: a BMI of 35 or higher; a BMI of 30 or higher plus heart failure with preserved ejection fraction, uncontrolled high blood pressure, or chronic kidney disease stage 3a or higher; or a BMI of 27 or higher plus prediabetes, a previous heart attack or stroke, or symptomatic peripheral artery disease.

Medicare.gov lists who isn't eligible: people already getting a GLP-1 covered through their Part D plan, and people with type 2 diabetes, moderate-to-severe sleep apnea or fatty liver disease. Their Part D plan may cover a GLP-1 for those conditions instead.

How it works and what it costs

• Prior authorization: your prescriber submits a request certifying you meet the criteria and are using the drug with a diet and exercise program. KFF Health News reports that a CMS contractor, Humana, runs the central processing system and that prescribers don't need to be enrolled Medicare providers.
• Cost: $50 at the pharmacy for a one-month supply (28 or 30 days). The copay doesn't count toward your Part D deductible or out-of-pocket cap. Extra Help can't lower it, and the Medicare Prescription Payment Plan can't spread it out.
• Duration: an approval covers refills and dose changes through December 31, 2027, unless you switch to a different GLP-1.
• Limits: the Obesity Medicine Association reports one-month fills only (no 60- or 90-day supplies) and, citing CMS FAQs, no appeals under the Bridge.

Because the Bridge runs outside the plans, CMS says Part D sponsors don't take on financial risk for these drugs. Before you switch plans, ask 1-800-MEDICARE whether the change affects an existing Bridge approval. We couldn't find a CMS statement that answers this directly.

If you have type 2 diabetes or another covered condition

Here open enrollment works the usual way: your plan's formulary decides your cost.

• Oral semaglutide for diabetes: in the U.S., Rybelsus is moving to a new name. The FDA approved "Ozempic" as the name for Novo Nordisk's oral semaglutide tablets in February 2026, and the Ozempic pill (1.5, 4 and 9 mg) launched in May 2026. Some 2027 formularies may list Ozempic tablets, Rybelsus or both. Search for the exact product and strength you take.
• Wegovy for heart-risk reduction: Wegovy tablets are also FDA-approved to reduce major cardiovascular events in adults with established cardiovascular disease and obesity or overweight. KFF lists cardiovascular risk reduction among the uses Part D can cover. Whether a given plan covers it, and with what prior authorization, varies.
• Foundayo isn't FDA-approved for type 2 diabetes as of October 2026, so Medicare's route for it is the Bridge.

For how plans review these drugs, see our guide to who qualifies for an oral GLP-1 prescription and insurance coverage and prior authorization.

2027 prices: negotiated, deal-based and self-pay

Three different pricing stories are moving at once, and they get confused easily.

1. Medicare's negotiated price for semaglutide

Under the Medicare Drug Price Negotiation Program, CMS announced in November 2025 a 2027 price for semaglutide. Managed Healthcare Executive reported $274 for a 30-day supply, about 71% below list, covering Ozempic, Rybelsus and Wegovy and effective January 1, 2027. Fierce Pharma reported the same $274 figure for Ozempic and a separate figure for higher-dose Wegovy. Either way, this is the price Medicare pays, not your copay. Your plan still sets your cost sharing.

2. The November 2025 manufacturer agreements

On November 6, 2025, the administration announced pricing agreements with Eli Lilly and Novo Nordisk. AJMC reported a $245 Medicare price for several GLP-1s, a $50 monthly Medicare copay, and $150-a-month starting doses for future oral GLP-1s sold through TrumpRx. AJMC also describes the Bridge's cost split: a $245 negotiated monthly price, with the beneficiary paying $50 and the federal government $195.

3. Self-pay cash prices

Prices listed October 2026; confirm at checkout:

When we checked TrumpRx.gov in October 2026, Foundayo wasn't listed on the page we saw, although April 2026 news reports said it would be offered there. Manufacturer copay savings cards exclude government beneficiaries, including people with Medicare. Self-pay programs have their own terms; read them before you buy.

For many eligible enrollees, the $50 Bridge copay costs far less than the cash prices above. If you don't qualify for the Bridge, for example because your BMI is below the thresholds, cash pricing may be your realistic option. Our pricing hub and cheapest oral GLP-1 guide compare them.

Other Part D changes for 2027

• Out-of-pocket cap: rises to $2,400 in 2027, from $2,100 in 2026. The standard deductible rises from $615 to $700 (Gray News, Oct. 15, 2026). Bridge copays don't count toward either.
• Premiums: the temporary Part D premium stabilization demonstration ends after 2026, and plans go back to standard premium setting for 2027, according to AJMC and Gray News. Compare premiums yourself. Don't assume this year's premium carries over.
• Plan pressure: AJMC reported in August 2026 that rising GLP-1 spending is straining Part D plans and could affect formulary and coverage decisions. That's one more reason to check the 2027 formulary even if you're happy with your current plan.

Open-enrollment checklist

• Decide which route applies to you. Weight management goes through the Bridge. Diabetes, heart-risk reduction or another covered use goes through your Part D plan's formulary.
• Make sure you'll have Part D on January 1. The Bridge requires Medicare drug coverage.
• Use Medicare Plan Finder at Medicare.gov/plan-compare. Enter your exact drug and strength (for example, Ozempic tablets 4 mg, not just "semaglutide") and your pharmacy.
• Check each plan's formulary: whether the drug is listed, its tier, and any prior authorization, step therapy or quantity limits for 2027.
• Compare total yearly cost, premium plus expected drug costs, not the premium alone.
• Ask about Bridge eligibility at Medicare.gov/glp1bridge or 1-800-MEDICARE (1-800-633-4227) and talk to your prescriber about the BMI and condition criteria.
• Ask whether switching plans affects an existing Bridge approval before you switch.
• Get free one-on-one help from your State Health Insurance Assistance Program (find yours at shiphelp.org) if you're comparing several options.
• Submit by December 7.

This guide is general information, not insurance, legal or medical advice. Medicare rules and program terms can change. Confirm details with Medicare.gov, 1-800-MEDICARE, your plan, or your State Health Insurance Assistance Program (SHIP) before you enroll or switch.