Why open enrollment is the only window that matters for GLP-1 coverage
If you take a GLP-1 medication or you are thinking about starting one, open enrollment is the one time each year you can meaningfully change what your health plan pays for. Once your 2027 election is locked in, the plan rules follow you all year unless you experience a qualifying life event. Most employer open-enrollment windows run mid-October through mid-December of 2026 for coverage that begins January 1, 2027. That leaves a narrow window to actually read the plan documents, ask the right questions, and make a decision that is not based on last year’s assumptions.
This matters more than usual heading into 2027. Employer plans have been under budget pressure from GLP-1 utilization for two years now, and independent policy trackers such as the KFF state-by-state analysis of obesity treatment coverage have documented steady tightening across private and public plans. What was covered in your 2025 plan may not be covered the same way in 2027. What your coworker gets covered may not match what you get covered, because plan design varies by pharmacy benefit manager and by employer contract.
Before we get to the questions: the rest of this guide is educational information, not medical advice, legal advice, or insurance advice. Your specific plan document and your clinician’s judgment govern what applies to you. Save your HR emails, plan documents, and any written answers you receive during open enrollment in one folder. Coverage disputes later in the year are resolved by paperwork, not by memory.
The 9 questions to ask HR before you re-enroll
These questions are ordered from most-common gotcha to most-specific detail. Ask them in writing whenever possible — email or HR-portal message — so you have a paper trail. If HR responds verbally, follow up with a short email summarizing the answer and asking them to confirm.
1. Does the 2027 plan cover GLP-1 medications for weight management, not just for type 2 diabetes?
This is the single most important question and the one most likely to have changed. Many plans cover tirzepatide or semaglutide when prescribed for type 2 diabetes but exclude the same molecules when prescribed for weight loss. Others cover Zepbound for weight management but not Wegovy, or vice versa. Ask specifically about Wegovy, Zepbound, and any generic or compounded equivalents. A vague answer such as “we cover weight-loss drugs” is not enough — ask which specific medications and under which diagnosis codes.
2. Is there a formal weight-loss exclusion in the 2027 plan document?
Some employers have added explicit weight-loss carve-outs to the plan document itself. If yours has one, the medication is not covered regardless of medical necessity in most cases, and no amount of prior-authorization paperwork will change that. Ask HR to point you to the exact section of the summary plan description that addresses weight-loss coverage, and get it in writing. If a carve-out exists, ask whether a medical-necessity exception process is available for documented comorbid conditions such as type 2 diabetes, obstructive sleep apnea, or cardiovascular risk.
3. What are the BMI and clinical criteria for coverage?
Pharmacy benefit managers set specific criteria that must be met for coverage. Common 2027 thresholds include BMI of 30 or higher, or BMI of 27 or higher with at least one weight-related comorbid condition such as hypertension, prediabetes, sleep apnea, or dyslipidemia. Some plans have raised the threshold to BMI 32 or higher. Ask HR or the pharmacy benefit manager for the exact written criteria your plan applies for 2027. If you qualified in 2025 or 2026, do not assume you still qualify.
4. Is step therapy required, and what medications must be tried first?
Step therapy means the plan requires you to try one or more lower-cost medications before it will approve a GLP-1. In 2027, many plans require documented trials of older weight-management options such as phentermine, Contrave, Qsymia, or in some cases metformin, before approving Wegovy or Zepbound. Ask what step-therapy medications your plan requires, how long you must document their use, and what “failure” means — typically a defined percentage of weight loss not achieved after a set number of weeks. Ask whether your clinician can request a step-therapy exception based on medical history.
5. What is the prior-authorization process and how long does approval take?
Nearly all GLP-1 coverage requires prior authorization. Ask how long a typical PA takes to process on your 2027 plan, what documentation your clinician needs to submit, and how you will be notified of the decision. Standard PAs are decided within 15 to 30 business days on most commercial plans; expedited urgent reviews are faster. Ask about the appeal process if PA is denied. If your PA is currently in place for 2026, ask whether it carries over to 2027 or requires re-submission.
6. What is my out-of-pocket cost after coverage?
Coverage does not mean free. Ask specifically about your 2027 co-pay or coinsurance for Wegovy and Zepbound, whether the medication counts toward your deductible, and what the maximum out-of-pocket exposure looks like across the year. GLP-1s frequently sit on the highest tier of a plan formulary, which can mean $50 to $200 or more per month even with coverage. If your plan has a deductible you have not met, your first several months of coverage may effectively cost you retail price. Confirm whether manufacturer copay-assistance programs are compatible with your plan — some employer plans exclude accumulator programs.
7. Which pharmacies can I use, and does mail-order change the cost?
Some plans require GLP-1 prescriptions be filled through a specific mail-order pharmacy or specialty pharmacy, and using a retail pharmacy instead can either raise your cost significantly or void coverage entirely. Ask whether the 2027 plan restricts GLP-1 dispensing to a preferred network. Ask whether 90-day mail-order fills are cheaper than 30-day retail fills. If the mail-order pharmacy has been slow or unreliable in the past, factor that into your decision about which plan to elect.
8. What happens if I change jobs mid-year?
If you elect a plan that covers your GLP-1 for 2027 and then change employers mid-year, your coverage ends when your employment ends. A new employer’s plan may cover the medication differently or not at all, and PA approvals do not transfer. Ask HR what happens to in-progress PAs and refills if you leave, and consider COBRA continuation cost if a job change is on the table. This question is especially relevant for anyone with a scheduled titration that runs across a potential job transition.
9. Is the plan’s pharmacy benefit manager changing for 2027?
Employers sometimes switch pharmacy benefit managers between plan years, and a new PBM can bring a new formulary with different tier placements, different PA requirements, and different preferred medications. If your employer is switching PBMs for 2027, treat the entire coverage question as if you are enrolling in a brand-new plan — do not assume anything carries over. Ask HR whether the PBM is changing and, if so, when the new formulary will be published so you can review it before the enrollment deadline.
If coverage is not there for 2027
If the answers above add up to “my plan does not cover this in 2027” — either because of an exclusion, a BMI threshold you no longer meet, or a step-therapy wall — you have practical options. None of them require you to wait until next open enrollment.
Manufacturer direct-pay programs
Eli Lilly’s direct-pay program for Zepbound single-dose vials publishes tiered pricing starting around $299 per month at the 2.5 mg dose and rising with higher doses; refill pricing is higher if a 45-day check-in is missed. LillyDirect also offers Zepbound in vial format at tiered dose-based pricing. Novo Nordisk offers various savings programs for Wegovy, and eligibility depends on insurance status. These programs change frequently — verify current terms directly on the manufacturer sites before making a decision. Both are legitimate paths for patients who want brand-name FDA-approved medication.
Cash-pay compounded telehealth
Cash-pay compounded tirzepatide through telehealth practices typically ranges from about $232 to $449 per month depending on the provider. Some practices layer a separate membership fee on top of the medication price. Some do not. Compounded tirzepatide is prepared by licensed compounding pharmacies under physician supervision, and compounded medications are not FDA-approved products. If you are comparing providers, our full telehealth pricing comparison walks through what Henry Meds, Mochi, Ro Body, LillyDirect, and SkinnyVIP each charge and what is included.
HSA and FSA funds
GLP-1 medications prescribed by a licensed clinician are generally eligible expenses for both Health Savings Accounts and Flexible Spending Accounts because they are prescription medications. This applies whether you go the brand-name route or the compounded route. Our HSA and FSA guide for GLP-1 costs covers what qualifies and what documentation to keep.
If your PA is denied later in the year
If you elect a plan that appears to cover GLP-1s but your prior authorization is denied after you enroll, the appeal process is still available. Our GLP-1 prior authorization denial checklist walks through the 7 questions to ask your insurer, what your clinician needs to submit, and how the internal and external review process actually works.
How SkinnyVIP handles this
SkinnyVIP lists a $695 three-month plan (about $232 per month) or a $350 single-month plan. The stated price applies across the 2.5 mg to 15 mg dose range — it does not rise solely because the dose changes. There is no membership fee and no auto-renewal. Consultation, medication, supplies, and shipping are included. No insurance paperwork is required from you. Current details are on the SkinnyVIP pricing page.
SkinnyVIP offers telemedicine via a nationwide telemedicine platform. A licensed clinician reviews your health history to determine whether treatment is appropriate; prescription is not guaranteed. SkinnyVIP does not itself prescribe — a licensed clinician does. Compounded medications are prepared by licensed compounding pharmacies under physician supervision. Compounded medications are not FDA-approved products. Individual results vary. Not affiliated with Novo Nordisk (Ozempic®/Wegovy®) or Eli Lilly (Mounjaro®/Zepbound®). If you want to see the clinical pathway alongside the numbers, review the $232/mo compounded tirzepatide overview.