Open Enrollment 2027: How to Pick a Health Plan That Covers GLP-1s

The fastest way to confirm GLP-1 coverage for 2027 is to download each plan’s drug formulary, search for your medication’s National Drug Code (NDC) and check the restriction column for terms like “step,” “PA” or “exclusion.” If a plan lists Wegovy, Ozempic, Zepbound or Mounjaro at a specialty-tier copay with prior authorization, you will pay only that copay once the PA is approved, but if the drug is excluded you will pay the full list price unless you qualify for a manufacturer savings card. Choosing the right plan now prevents surprise denials and thousands of dollars in uncovered costs next year.

• Marketplace open enrollment for 2027 runs November 1, 2026 through January 15, 2027 in most states.
• Only about one in four individual plans listed a weight-loss GLP-1 on formulary for 2026; expect similar rates for 2027 unless your state has passed an obesity-care mandate.
• Plans that cover Wegovy often require prior authorization proving at least 12 weeks of intensive lifestyle counseling and a body-mass index (BMI) of 30 kg/m² or 27 kg/m² plus one weight-related condition.
• Employer self-funded plans can carve GLP-1 coverage in or out mid-year, so ask Human Resources for the 2027 Summary of Benefits and Coverage as soon as it is available.
• Manufacturer self-pay options, such as NovoCare home delivery for Wegovy ($1,349.02 per month)(novocare.com) and Lilly’s list price for Zepbound ($1,059.87 per month)(investor.lilly.com), cap what you would owe if your plan excludes the drug.

Open enrollment lets you lock in drug coverage for a full calendar year

Open enrollment is the once-a-year window when you can choose a new individual Marketplace plan, switch Medicare Advantage or Part D drug plans, or elect among employer plan options without showing a qualifying life event. Economists note that consumers rarely switch once the window closes, even if they later find gaps in coverage (Decarolis et al., 2020). That makes November 1 to January 15 your single best chance to secure GLP-1 benefits for the entire 2027 plan year.

Why timing counts: Outside open enrollment you can move plans only after certain events (for example losing other coverage or moving). If your 2026 plan excluded Wegovy and you miss this window, you will likely pay cash for another year.

Download the formulary and search by National Drug Code

Every health plan publishes a searchable PDF formulary online. The fastest method is to press Ctrl + F and type the drug’s NDC or brand name. Coverage usually falls into four buckets:

Covered without restrictions: Appears with a tier number and no footnotes. You pay the copay or coinsurance once you meet any deductible.

PA (prior authorization): Requires your prescriber to submit paperwork proving you meet BMI and lifestyle-change requirements.

ST (step therapy): You must try another medication first, commonly phentermine tablets for 90 days.

NC / Excluded: Not covered for any indication; you pay the cash price.

Marketplace websites now offer better decision-support tools, including integrated provider look-ups and total cost estimators, yet studies show consumers still struggle to interpret drug tiers correctly (Wong et al., 2016). Printing the formulary and highlighting each GLP-1 can prevent mistakes.

Look beyond premiums to the real yearly cost

Cheaper monthly premiums can lure shoppers, but the key figure for GLP-1 users is the annual out-of-pocket maximum for prescription drugs. Plans with low deductibles and coinsurance caps often cost less by year’s end if you need a $1,000-plus medication every month.

Use the total cost calculator: Most Marketplace sites ask a few questions about chronic medications, then estimate yearly pharmacy spend. Although consumers appreciate these tools, qualitative research found they still want clearer explanations of cost drivers (Faugno et al., 2023). Cross-check the calculator figure with the worst-case scenario: list price times 12 minus any manufacturer savings you qualify for.

Expect stricter prior-authorization criteria for 2027

Insurers tightened rules in 2026 to curb soaring GLP-1 spending, and nothing indicates a rollback for 2027. Common requirements include:

BMI thresholds: BMI ≥30 kg/m², or ≥27 kg/m² with at least one comorbidity such as hypertension or sleep apnea.

Lifestyle documentation: Six to twelve months of supervised diet and exercise notes or a structured weight-management program.

Discontinuation rule: A minimum 5% weight loss by six months or the plan may deny refills.

One GLP-1 at a time: Switching from Ozempic to Zepbound usually requires a new PA and another lifestyle note.

Understanding these hurdles helps you estimate how often your clinic will need to fax forms and whether you can meet the timeline. See our detailed guide How to Get Zepbound Covered by Insurance for a line-by-line look at PA forms.

Key questions to ask your employer’s benefits team

Large employers often offer two or three plan tiers, and the glossy comparison chart rarely mentions drug exclusions. Use the questions below in your next HR meeting:

“Is obesity medication carved out?” Some self-funded plans save money by excluding weight-loss drugs entirely.

“Which pharmacy benefit manager administers the formulary?” CVS Caremark and Express Scripts each released 2026 exclusions lists in August; those hint at 2027 rules.

“Do we have a medical necessity override process?” An override can allow coverage if prior treatments failed.

“Can I contribute to an HSA?” High-deductible health plans paired with Health Savings Accounts let you pay GLP-1 copays with pre-tax dollars, reducing effective cost.

You will find more employer-specific strategies in our companion article My Employer Dropped GLP-1 Coverage: What Now?.

Fallback strategies if coverage is denied

No plan is perfect, so build a backup plan before January 15.

Appeal the denial: Submit clinical notes showing past weight-loss attempts and comorbidities. Most commercial insurers must respond within 30 days.

Manufacturer savings cards: Commercially insured patients may pay as little as $25 for Wegovy or $25 for Zepbound if the drug is on formulary, though income caps apply. Cash-only NovoCare home delivery for Wegovy offers introductory doses at $199 per month for eligible self-pay patients (0.25 mg or 0.5 mg)(novocare.com).

Medicare GLP-1 Bridge: If you are transitioning to Medicare in 2027, ask about the CMS pilot that temporarily covers anti-obesity medications for certain beneficiaries through 2029.

Compare cash prices locally: Use the free Rx.com discount card to see if a retail pharmacy beats the plan’s coinsurance for lower Wegovy starter doses.

HSA budgeting: Max out your 2027 HSA contribution ($4,150 single; $8,300 family) to buffer first-year costs.