Open Enrollment starts October 15 and drug plans are sending out the Annual Notice of Changes now. Going into 2027, one drug may cause confusion as beneficiaries try to figure out whether they can get it. That drug is Wegovy. But the why, how and how much will depend on the individual circumstances.
A Little History
When Part D was being put together, the medications available for weight loss had limited effectiveness and were perceived to be used primarily for cosmetic purposes. So, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 explicitly restricted Medicare coverage of weight-loss drugs.
But things started to change in June 2021 when the Food and Drug Administration approved Wegovy as the first drug for chronic weight management in adults. Three years later, in May 2024, the FDA approved Wegovy as the first treatment to reduce the risk of cardiovascular death, heart attack and stroke in adults with cardiovascular disease and either obesity or overweight. With the approval for a medical indication, Wegovy became a medication that a Part D prescription drug plan could provide. The primary purpose would be to reduce risk with weight loss being an extra benefit. However, in 2026, I could not find one plan (stand-alone or Medicare Advantage) that covers this medication. Cost might play a factor in that. The list price for a month’s supply is about $1,330.
In June, the Centers for Medicare and Medicaid Services opened the door to alternative coverage when it introduced the Medicare GLP-1 Bridge. Under this short-term demonstration, from July 1, 2026, through December 31, 2027, eligible Part D beneficiaries will have access to selected GLP-1 drugs for a $50 copayment. (Read more about this demonstration.) Wegovy is one of the three drugs included in the demonstration.
Then, beginning January 1, 2027, Medicare prescription drug plans must cover Wegovy. That’s because it is on the 2027 list of Part D negotiated drugs. Once the drug companies and CMS have agreed to a negotiated price for any drug, plans must include it in their formularies
Two Coverage Paths
Next year, Medicare beneficiaries will have two ways to get Wegovy:
- Through Part D prescription drug coverage (a stand-alone plan or coverage included in another plan, such as Medicare Advantage or retiree), or
- As a participant in the Medicare GLP-1 Bridge.
However, there will be two different costs and sets of eligibility criteria.
For Part D coverage:
- The drug must be prescribed to reduce the risk of major cardiovascular events (heart attack, stroke, or cardiovascular death) in adults with heart disease and overweight or obesity. (Weight loss can be a benefit.)
- The maximum fair price coming out of negotiation is $274.
- Those who qualify must get the drug through a network pharmacy.
- Prior authorization will no doubt be required to confirm the beneficiary demonstrates a cardiovascular risk and is overweight.
- As long as the individual qualifies, the drug will be covered.
For those in the Medicare GLP-1 Bridge, weight loss and weight loss management are the primary goals. There are three levels of qualifying criteria:
- A BMI of 35 or greater (no previous diagnoses, history or risk), or
- A BMI of 30 or greater with a diagnosis of diastolic heart failure, uncontrolled hypertension or chronic kidney disease Stage 3a or higher, or
- A BMI of 27 or greater with pre-diabetes, previous myocardial infarction or stroke, or symptomatic peripheral artery disease.
The cost is $50 and any pharmacy that wants to can participate so networks are not a concern. The pharmacy’s first claim will be rejected and then sent back to the physician to show the patient complies with the BMI and history or diagnosis criteria.
The demonstration project is scheduled to end December 31, 2027.
Out of Luck
There are some who will not qualify under either type of coverage, including:
- Beneficiaries under a 35 BMI who do not demonstrate cardiovascular risk (If they did, they would qualify for Part D coverage), and
- Beneficiaries with a BMI between 27 and 30 who do not have pre-diabetes, symptomatic peripheral artery disease, uncontrolled hypertension or chronic kidney disease Stage 3a or higher. (They don’t meet the criteria for Part D or the Medicare GLP-1 Bridge.)
Their only option will be to shop around for cost-saving offers.
One More Drug
Ozempic was included in the BALANCE Model, a five-year demonstration that preceded the Medicare GLP-1 Bridge to increase access to medications for weight loss. This model never got off the ground and when CMS introduced the current bridge model, Ozempic did not make the cut. Today, many, but not all, plans cover this drug and cost sharing is all over the map.
However, this drug is a 2027 negotiated drug and Part D plans must list it in their formularies. The negotiated price is the same as for Wegovy, $274. To qualify, the beneficiary must meet some very specific eligibility criteria, established by the FDA. Ozempic is approved for adults with type 2 diabetes:
- To improve glycemic control
- To reduce the risk of major adverse cardiovascular events in those who also have an established cardiovascular risk, and
- To reduce the risk of kidney failure in those with chronic kidney disease.
Quick Points to Remember
- Part D coverage of Wegovy focuses on risk reduction; the Medicare GLP-1 Bridge targets weight loss with certain diagnoses supporting lower BMIs.
- Part D coverage will no doubt cost more but there is no end date. The Bridge offers a lower price but there is a coverage cliff. This is a demonstration that will end December 31, 2027.
- Most important, Part D members cannot choose which way to get the drug. Those who qualify for Part D coverage would be excluded from the GLP-1 Bridge. And, vice versa, those who can get the drug through the Bridge would not qualify under Part D.
Going forward, discuss your situation with a physician to determine whether and how you might qualify for Wegovy or Ozempic. Then, check out your coverage options, put together a plan and budget, and start on the path to improved health.
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