Ask what your plan will pay

Translate the plan’s words

The plan’s drug list

The medicines covered by a plan appear on its list called a formulary.

Approval before payment

Prior authorization means the insurer has to agree ahead of time.

Ask who submits that request, what information is needed, and what happens if it is denied.

For Medicare, the reason for use matters

Medicare helps with medicine bills through its Part D coverage.

Rules checked September 26, 2026 exclude drugs taken solely to lose weight from ordinary Part D payment.

Payment through Part D may be available for a medicine used to treat another accepted health condition. The plan’s drug list and advance-approval rules still apply.

Your plan must still agree to pay.

There is a separate temporary route

GLP-1 medicines imitate a signal in the body linked to hunger and blood sugar.

Medicare’s temporary GLP-1 Bridge program helps some people pay for weight medicines. Its rules were checked September 26, 2026.

People who qualify pay $50 for each month’s supply of a covered medicine. This payment is called a copay: their part of the medicine bill.

Ask separately what you would pay for visits and tests.

For the Bridge, the start is July 1, 2026; the finish is December 31, 2027. It operates outside the usual Part D benefit.

Each year, Part D caps your payments for medicines it covers. Bridge payments do not move you closer to that limit.

You cannot lower the Bridge payment with a coupon.

Who may use the Bridge?

These are the main checks from Medicare’s rules dated September 26, 2026. They do not confirm that you qualify.

You must be at least 18. Your plan must cover drugs through either Part D or Medicare Advantage; some plan types are excluded.

Ask your plan to confirm whether its type can use the Bridge.

The weight check uses BMI, which combines your weight and height in one number. The program uses the BMI you had at the start of GLP-1 treatment.

Ask the person treating you to check which of these groups fits your health record.

• BMI 35 or more: no extra diagnosis from the groups below is needed for this weight check.
• BMI 30 or more: you also need one of three specific heart, blood-pressure, or kidney diagnoses.
• The required heart diagnosis is “heart failure with preserved ejection fraction”. Check with your clinician that your record names this exact diagnosis.
• The blood-pressure check requires a top number over 140 or a bottom number over 90 mm Hg, even with two medicines for blood pressure.
• The kidney rule is chronic kidney disease at stage 3a or later. Ask your clinician for the stage in your record.
• BMI 27 or more: you also need one of these: pre-diabetes; a past stroke; a past heart attack; or limb-artery disease that causes symptoms.

The blood-pressure readings use mm Hg, the unit shown on a blood-pressure result.

Ask your clinician whether your blood-sugar diagnosis is pre-diabetes or type 2 diabetes. The program treats them differently.

Under the September 26, 2026 rules, people who have type 2 diabetes take the ordinary Part D route instead.

Other exclusions include moderate to severe obstructive sleep apnea: blocked breathing during sleep. A specific liver diagnosis is also excluded.

The excluded liver diagnosis is noncirrhotic MASH with liver scarring that is moderate to advanced. It does not exclude every fatty-liver diagnosis.

Ask your clinician whether either exclusion matches your health record, or whether the prescription belongs under ordinary Part D for another approved use.

For 2026, the Bridge excludes anyone whose GLP-1 medicine received Part D payment during 2026.

The rules need a prescription and approval in advance. Treatment must include a continuing plan that covers both nutrition and physical activity.

The covered products are semaglutide (Wegovy), as tablets or injections; tirzepatide (Zepbound), in the KwikPen device; and orforglipron (Foundayo) tablets.

Zepbound’s single-dose bottles and single-dose pens are excluded.

Take the exact medicine name and form to your plan and clinician. Ask them to check all the rules before counting on the $50 price.

For other coverage, get a plan-specific answer

• Is this exact product covered for my diagnosed condition?
• What would I pay at the pharmacy?
• Are visits and tests covered separately?
• How often does approval need to be renewed?