Medicare Open Enrollment and GLP-1s: 2026 Cost Checklist
Released · Last reviewed
Between October 15 and December 7, 2026, a Medicare enrollee taking a GLP-1 should check three things: whether they qualify for the Medicare GLP-1 Bridge ($50 a month through December 31, 2027, per CMS), whether a Part D plan covers their drug for a covered condition, and the 2027 Part D cap of $2,400.
The catch: Bridge copays do not count toward that $2,400 cap, and the cash prices below are 2026 prices that can change on January 1.
For a GLP-1, your plan choice matters a lot on some routes and barely at all on others. Here is the arithmetic. For background on the Bridge itself, see our Medicare GLP-1 coverage explainer.
What changes on January 1, 2027?
Three CMS numbers move:
- Part D deductible: $700 in 2027, up from $615 in 2026. That is $700 − $615 = $85 more.
- Part D out-of-pocket threshold: $2,400 in 2027, up from $2,100. That is $2,400 − $2,100 = $300 more exposure on covered drugs.
- Negotiated semaglutide price: $274 per 30-day supply for Ozempic, Rybelsus and Wegovy, against a $959 list price, a 71% discount.
The Bridge itself stays. It runs July 1, 2026 through December 31, 2027. A CMS FAQ about "the BALANCE Model not launching in Medicare in 2027" says the Bridge "will be extended through December 31, 2027." It says nothing about 2028.
Am I eligible for the $50 Bridge, and what doesn't it cover?
The Bridge charges $50 for a one-month supply (28 or 30 days), at any income. You must be 18 or older and, when you start, meet one of these:
- A BMI of 35 or higher.
- A BMI of 30 or higher plus HFpEF heart failure, uncontrolled high blood pressure, or kidney disease stage 3a or higher.
- A BMI of 27 or higher plus prediabetes, a past heart attack or stroke, or symptomatic peripheral artery disease.
Your prescriber must also certify a diet-and-exercise lifestyle program. The limits are where people get caught:
- Three drugs only. Foundayo (tablet), Wegovy (injection or tablet), and Zepbound in the KwikPen. The single-dose Zepbound pen and Zepbound vials are not covered.
- Certain diagnoses are excluded. If you have type 2 diabetes, moderate-to-severe sleep apnea, or fatty liver disease, you are not eligible. Medicare.gov says your Part D plan "might cover" a GLP-1 instead.
- Plan-paid users stay put. If your Part D plan already pays for your GLP-1, you keep getting it through the plan.
- The $50 sits outside your Part D math. It does not count toward the deductible or out-of-pocket limit, Extra Help cannot lower it, and the Prescription Payment Plan cannot spread it.
- Plan type matters. Standalone drug plans and Medicare Advantage drug plans qualify; private fee-for-service, cost plans and PACE do not.
Does my Part D plan choice change what I pay for a GLP-1?
On the Bridge: probably not. CMS runs it through "a single central processor," outside each plan's formulary. Our inference: any eligible plan type keeps you in, so choose on your other drugs, premium and pharmacy.
For a Part D-covered use: yes, a lot. CMS lists type 2 diabetes, moderate-to-severe sleep apnea, and MASH with moderate to advanced fibrosis as eligible for Part D coverage, plus Wegovy to cut cardiovascular risk in people with established heart disease. Every plan has its own formulary, and Medicare.gov warns that plans "can change their drug list at any time."
For weight loss alone, outside the Bridge criteria: no. Part D law excludes drugs "used for... weight loss," even for morbid obesity. That leaves cash.
Does the $274 negotiated price mean I pay $274?
No. This is our explanation, not CMS wording: the negotiated price (CMS calls it the maximum fair price) is what the plan pays for the drug. Your counter price still depends on your plan's deductible and tier. CMS gives only an overall estimate: $685 million in out-of-pocket savings across enrollees.
Also, the $385.63 figure is CMS's negotiated price for one package, Wegovy 2.4 mg with 4 pens. It is not a price for higher doses. And the negotiated price works inside Part D, so it does not change the Bridge's $50 or anyone's cash price.
How do the routes compare side by side?
| Route | Who can use it | What you pay | Counts toward $2,400 cap? | Source, read date |
|---|---|---|---|---|
| Medicare GLP-1 Bridge | Meets BMI criteria; no type 2 diabetes, moderate-to-severe sleep apnea or fatty liver disease | $50 / month | No | Medicare.gov fact sheet, read Oct 15, 2026 |
| Part D plan, covered condition | Type 2 diabetes, sleep apnea, MASH, heart risk (Wegovy) | Plan cost-sharing after $700 deductible | Yes | CMS Part D plan page; 2027 Announcement; read Oct 15, 2026 |
| NovoCare self-pay | Anyone, outside insurance | Wegovy pill $149–$299; pen $349; HD $399 | No | novocare.com, read Oct 15, 2026 |
| Lilly self-pay | Cash patients; Medicare use not verified | Zepbound $299–$699; Foundayo $149–$349 | Not stated by Lilly | zepbound.lilly.com, read Oct 15, 2026; LillyDirect archived Sept 25, 2026 |
| Compounded cash pay | Anyone; not FDA-approved | Varies by provider | No (cash-pay) | Provider sites; see our comparison |
NovoCare says "government-insured patients" may use its program if they self-pay outside their insurance, which covers Medicare enrollees to self-pay outside insurance. Lilly's page is unclear, so ask Lilly first. Current prices are on our GLP-1 Price Index.
What should I check before December 7?
- List your diagnoses. Type 2 diabetes, moderate-to-severe sleep apnea or fatty liver disease rules out the Bridge; your Part D plan might cover a GLP-1 instead, not the Bridge.
- Check your BMI category and plan type against the Bridge rules.
- Check the drug form. For Zepbound on the Bridge, it has to be the KwikPen.
- On the Part D route, look up your exact drug and dose on Medicare's Plan Finder, with tier and prior authorization.
- Budget the 2027 numbers: a $700 deductible and a $2,400 cap on covered drugs.
- Budget Bridge copays separately: 12 × $50 = $600 a year, outside the cap.
- Mark the dates. The plan must get your request by December 7. Medicare Advantage members get another window January 1 to March 31.
- Expect cash prices to move. NovoCare says its pricing will be updated after December 31, 2026, and the Bridge ends December 31, 2027.
What this means for you
Example 1: Bridge-eligible, on the Wegovy pill
BMI 36, no diabetes, standalone drug plan. On the Bridge, 12 months of Wegovy in 2027 costs 12 × $50 = $600. NovoCare self-pay at 25 mg would cost 12 × $299 = $3,588. The Bridge saves you $3,588 − $600 = $2,988 for the year. Neither amount counts toward the $2,400 cap.
Example 2: Type 2 diabetes, GLP-1 through Part D
You cannot use the Bridge, so your plan is the route. The deductible is $700 and covered-drug spending is capped at $2,400. If your drugs reach the cap, your worst case is $2,400 for the year, about $2,400 ÷ 12 = $200 a month. The Prescription Payment Plan spreads that into monthly bills without lowering it. A plan that leaves your drug off its formulary breaks this math, so step 4 matters most for you.
Example 3: BMI 28, no qualifying condition
Without prediabetes, a prior heart attack or stroke, or peripheral artery disease, a BMI under 30 does not qualify, and Part D excludes weight loss. Everything is cash:
- Wegovy pen via NovoCare: 12 × $349 = $4,188. If you started before December 31, 2026 with the two $199 new-patient fills: 2 × $199 + 10 × $349 = $398 + $3,490 = $3,888. See Wegovy without insurance.
- Zepbound self-pay at 7.5–15 mg with refills inside 45 days: 12 × $449 = $5,388. Miss the window at 10–15 mg: 12 × $699 = $8,388, which is $3,000 more. See Zepbound.
- Foundayo at 9 mg, from LillyDirect's page as archived September 25, 2026: 12 × $299 = $3,588. See orforglipron.
Compounded semaglutide and tirzepatide are not FDA-approved and are cash-pay; see our compounded pricing comparison.
Frequently asked questions
Can I use the Medicare GLP-1 Bridge if I have type 2 diabetes?
No. Medicare.gov says people with type 2 diabetes, moderate-to-severe sleep apnea, or fatty liver disease are not eligible for the Bridge. Their Part D plan might cover a GLP-1 instead, so check each plan's formulary for your exact drug and dose before December 7.
Do Bridge copays count toward the 2027 $2,400 out-of-pocket cap?
No. Medicare's fact sheet says the $50 payment does not count toward your drug plan deductible or yearly out-of-pocket limit. Twelve months of Bridge copays come to $600, and that sits entirely outside the $2,400 cap. Extra Help cannot lower it.
Will switching Part D plans change my Bridge access?
Probably not, as long as the new plan is an eligible type. CMS runs the Bridge through a single central processor outside each plan's coverage, and we found no rule tying it to a plan's formulary. That is our inference, not a CMS statement.
Can I use NovoCare self-pay prices if I have Medicare?
Yes, according to NovoCare. It says government-insured patients may use its program if they self pay and process outside of their insurance. Those payments do not count toward your out-of-pocket limit. Lilly's self-pay terms for Medicare enrollees are unclear, so ask Lilly first.
What happens after the Bridge ends on December 31, 2027?
Nobody has published that yet. A CMS FAQ refers to the BALANCE Model not launching in Medicare in 2027 and says the Bridge is extended through December 31, 2027, ahead of potential implementation of BALANCE in Part D. Treat 2028 costs as unknown and recheck next fall.
Sources
All read October 15, 2026, unless noted.
- Medicare.gov, GLP-1 Bridge fact sheet (June 2026).
- Medicare.gov, Weight loss drugs coverage.
- CMS, Medicare GLP-1 Bridge (last modified July 13, 2026).
- CMS, Information for Part D plans (last modified August 6, 2026).
- CMS Innovation Center, BALANCE Model page and FAQ (last modified September 29, 2026).
- CMS, CY 2027 Rate Announcement (April 6, 2026).
- CMS, Negotiated prices for 2027 (November 2025).
- CMS, Part D Manual, Chapter 6 (Rev. 10, 2010).
- Medicare.gov, Joining a plan and How drug plans work.
- Medicare.gov, Medicare Prescription Payment Plan.
- Novo Nordisk, NovoCare Wegovy self-pay offer.
- Eli Lilly, Zepbound savings and self-pay. Foundayo prices from LillyDirect, archived September 25, 2026; lilly.com was unreadable October 15.