Newsletter

WHAT EARLY CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) FILINGS SUGGEST FOR 2027 MA & MEDIGAP PLANS

Early 2027 filings with the Centers for Medicare and Medicaid Services (CMS) point to another year of tight margins for Medicare Advantage (MA) carriers. Rising utilization, higher hospital reimbursement demands, and pressure from GLP‑1 and other specialty drugs are pushing plans toward leaner benefits and more restructuring.

PPO Plans: Most Likely to Be Cut

PPOs remain the costliest MA product. Early filings suggest:

• More PPO terminations
• Shrinking service areas
• Tighter networks and reduced out‑of‑network coverage

This is especially important in snowbird states like Florida.

Impact on Medicare Supplement (Medigap) Plans: Unhealthier Members Will Drive Rate Pressure

When PPOs exit or shrink, affected members receive a Guaranteed Issue right to enroll in certain Medicare Supplement (Medigap) plans.

The key dynamic:

Unhealthier PPO members are the ones most likely to move into Medicare Supplement (Medigap) plans.

They need:

• Predictable costs
• No networks
• Fewer authorization barriers

This higher‑risk influx raises claims inside Medicare Supplement (Medigap) blocks, which leads to larger premium increases. This trend is expected to continue into 2027.

Medicare Advantage (MA) Benefits: Expect Higher Cost Sharing

To stay within CMS revenue limits, many 2027 MA plans are expected to:

• Raise specialist and hospital copays
• Reduce dental/vision/hearing allowances
• Shrink Over-the-Counter benefits
• Increase prior authorization

Giveback Plans: Likely to Decline

Giveback (Part B rebate) plans surged from 2021–2024, but filings show a pullback.

Expect in 2027:

• Fewer giveback plans
• Smaller giveback amounts
• Givebacks concentrated mostly in HMO plans

Bottom Line for 2027

Beneficiaries should expect:

• Fewer PPO options
• Narrower networks
• Higher Medicare Advantage (MA) cost‑sharing
• More high‑risk members entering Medicare Supplement (Medigap) plans
• Continued Medicare Supplement (Medigap) premium pressure
• Fewer and smaller giveback plans

Disclaimer:



This article provides general educational information only. It does not describe, predict, or market benefits for any specific 2027 Medicare Advantage, Part D, or Medicare Supplement plan, and the predictions included in this article might or might not come to fruition. Final 2027 plan benefits will not be available until the Centers for Medicare and Medicaid Services (CMS) releases approved plan data later in the year.

GLP-1 MEDICATIONS AND MEDICARE IN 2026

Coverage, Costs, Zepbound Exceptions, and New Options Outside Part D

GLP-1 medications such as Ozempic, Wegovy, Mounjaro, and Zepbound continue to transform diabetes, obesity, and cardiovascular care. Demand is soaring, and Medicare beneficiaries are asking what’s covered, what isn’t, and what alternatives exist when Part D won’t pay.

This guide breaks down the latest developments for 2026 — including the new trend of Zepbound approvals through formulary exceptions.

What’s New for 2026

• More GLP‑1 combination therapies and oral versions are approaching FDA approval.
• Medicare spending on GLP‑1s continues to rise, prompting tighter utilization controls.
• Federal law still prohibits Medicare from covering weight‑loss‑only medications.
• Part D plans are expanding GLP‑1 formularies but adding more prior authorization and step therapy.
• The Medicare Prescription Payment Plan [applicable only to MAPD (Medicare Advantage Prescription Drug) or stand-alone Part D coverage] continues to help spread out high drug costs over 12 months.

How Medicare Covers GLP-1 Medications

Covered Under Part D

Medicare Part D may cover GLP‑1 medications only when they have an FDA‑approved indication for:

• Type 2 diabetes, or
• Cardiovascular risk reduction

Examples:

• Ozempic → Covered (diabetes)
• Mounjaro → Covered (diabetes)
• Wegovy → Covered only for cardiovascular indication
• Zepbound → Not routinely covered (weight‑loss indication only)

Zepbound: The New Formulary‑Exception Trend

Although Zepbound is not normally covered under Medicare Part D because it is approved only for weight loss, some carriers are now approving it on a formulary‑exception basis.

When exceptions are being approved

• Strong medical‑necessity documentation
• Failure, intolerance, or contraindication to covered GLP‑1 medications
• Specialist physician involvement (endocrinology, cardiology, obesity medicine)
• Plan’s clinical team determines Zepbound is the only clinically appropriate option

Examples of approved cases

• Severe obesity with multiple high‑risk comorbidities
• Documented intolerance to Ozempic, Mounjaro, or Wegovy
• Rare off‑label diabetes management under specialist supervision

Important

• Approvals are not guaranteed
• Requirements vary by carrier
• Prior authorization is always required
• Exception approvals do not change Medicare’s statutory exclusion of weight‑loss drugs

Bottom line: Zepbound remains excluded under federal law, but real‑world exceptions are happening, and more carriers are open to reviewing these requests in 2026.

Options Outside Medicare Part D

Because Medicare cannot cover weight‑loss‑only medications, manufacturers and carriers have created alternative pathways.

1. Manufacturer Cash‑Pay Programs

Examples:

• Eli Lilly (Zepbound): Cash‑pay program typically $399–$549/month
• Novo Nordisk (Wegovy): Discounted self‑pay pricing through select pharmacies

These programs:

• Are cash‑only
• Cannot be combined with Medicare Part D
• Are available to Medicare beneficiaries because they are not insurance

2. Telehealth Weight‑Management Programs

Companies such as Ro, Calibrate, and Found offer:

• Medical supervision
• Lifestyle coaching
• Access to GLP‑1 medications at negotiated cash prices

Typical pricing:

• $99–$199/month for the program
• $299–$599/month for medication

These operate entirely outside Medicare.

3. Compounded Semaglutide and Tirzepatide

• Typically $150–$350/month
• Not FDA‑approved
• Quality varies by pharmacy
• Florida allows compounding, but oversight is increasing

A buyer‑beware option.

4. Medicare Advantage Supplemental Benefits

• Some MA plans are pilotin discounted cash‑pay GLP‑1 pricing
• Telehealth weight‑management programs
• Lifestyle coaching

These are not Part D benefits, but value‑added extras. These extras can be communicated by carriers and agents only after enrollment in a Medicare Advantage plan occurs. Check with your plan and carrier to see if your plan offers value-added GLP-1 pricing as a value-added benefit.

What This Means for You

• Check your Part D formulary for diabetes‑related GLP‑1 coverage.
• Ask your doctor whether a Zepbound formulary exception is appropriate.
• Compare cash‑pay programs if using GLP‑1s for weight loss.
• Be cautious with compounded medications.
• Review Medicare Advantage supplemental value-added benefits for weight‑management support.
• Use the Medicare Prescription Payment Plan to spread out high drug costs (does not apply to cash pay benefits; applied only to MAPD plans or stand-alone Part D coverage).

Bottom Line



GLP‑1 medications are expanding rapidly, but Medicare’s coverage rules remain strict. For weight‑loss‑only use, beneficiaries must rely on cash‑pay programs, telehealth bundles, or supplemental MA benefits — unless a formulary exception is approved.

Zepbound remains excluded under federal law, but some carriers are now approving it case‑by‑case, making it an important option to watch in 2026.

TrumpRx.co: WHAT MEDICARE BENEFICIARIES SHOULD KNOW

A new discount program is drawing attention — but it’s important to understand what it is and what it isn’t.

TrumpRx.co is a prescription discount website that offers lower cash prices on certain medications. It works similarly to GoodRx, SingleCare, and other coupon platforms: you search for your medication, download a coupon, and present it at participating pharmacies.

Key points for Medicare beneficiaries:

• It is not insurance. Using a coupon means you are paying the pharmacy’s cash price, not using your Medicare Part D plan.
• Cash payments do not count toward your Part D deductible or out‑of‑pocket maximum.
• Prices vary widely. Some drugs may be cheaper than your plan copay; others may not.
• Useful for non‑covered drugs. If your Part D plan excludes a medication, a discount card can sometimes offer a lower cash price.

When it may help:

• Your plan’s copay is unusually high.
• You take a medication not on your plan’s formulary.
• You want to compare cash prices before filling a prescription.

When to be cautious:

• If you are working toward the Part D deductible or catastrophic phase.
• If you take expensive brand‑name medications where coupons rarely beat insurance pricing.

Bottom line: TrumpRx.co is another tool in the toolbox — but Medicare beneficiaries should compare prices carefully and understand that discount cards do not coordinate with Part D (i.e., prices paid under TrumpRx.co do not count toward Part D deductibles or toward the catastrophic limit.

About Paul Cholak

Paul is a licensed, independent health and life insurance agent and has over forty years of benefits experience and specializes in helping Medicare beneficiaries obtain health insurance. However, he offers a complete array of life and health insurance products to individuals of all ages.

He guides Medicare beneficiaries through the steps of getting insurance and is available to help clients both BEFORE and AFTER they've made their purchase decision.

Disclaimer for Part C and D plans: "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE (TTY: 1-877-2048) to get information on all your options."

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