GLP-1 Open Enrollment: A Checklist for Comparing Health Plans

The short answer

Before choosing next year's health plan, confirm the exact drug, the condition being treated, the coverage rules and your likely annual cost. A low premium is only one part of the decision. A drug appearing on a general formulary is not the same as your employer purchasing that benefit.

Use this checklist while both plans are still available to choose. It is designed for open enrollment; if your current claim has already been denied, start with our denial and appeal guide.

Gather documents for the year you are choosing

Ask benefits staff for the Summary of Benefits and Coverage, full plan documents, prescription formulary and the drug's coverage criteria for the coming plan year. HealthCare.gov explains that individual and employer plans must provide an SBC, including during enrollment and renewal. It is a useful standardized starting point for comparing benefits, but it is not a personalized pharmacy quote.¹

Save each document with its plan name and effective date. Two plans can use the same insurance company and still have different benefits. An online search result may also be stale: the Express Scripts Basic Formulary link we opened on October 13, 2026 displayed a 2027 document. That general list itself directs members to their own coverage information; it does not establish your employer's choice.²

Six answers to get before the deadline

Send the same questions to both plans. “GLP-1s are covered” leaves too much unresolved. “This plan covers my prescribed Wegovy formulation for chronic weight management if I meet these attached criteria” is a more useful answer. Ask for a written response or document reference and keep the representative's case number.

Prior authorization is a clinical coverage review, not merely a form you can complete alone. Express Scripts says the prescriber supplies the necessary information and members can track review status online. Ask the clinic what it needs from you before the new plan starts.³

Work the annual numbers, not just the first refill

Here is an illustrative worksheet, not a quote or a prediction of coverage. Both hypothetical plans cover the same prescribed drug, approval is assumed, and neither example includes a manufacturer coupon. Twelve monthly medication payments are assumed solely to make the arithmetic clear.

Under those assumptions, Plan B costs $900 less despite its higher premium. The $1,200 premium difference is outweighed by $2,100 in lower medication spending. These numbers stop being useful if approval fails, another family member needs expensive care, or the quoted copay applies only after a deductible.

Replace the medication row with your actual benefit estimate. Do not add the full deductible on top of a pharmacy estimate that already includes it. Ask the plan to explain whether the quote assumes the deductible has been met. Keep employer HSA contributions as a separate line, and avoid counting the same employer contribution twice.

Run a second scenario with no drug coverage

Make a second copy of the worksheet with the medication benefit unavailable. Use a current, written cash quote for the exact product if your clinician considers that an option. Include any required clinic membership separately. Do not substitute an introductory compounded-medication advertisement for a recurring brand-name prescription cost.

Then ask a household question: could you manage that scenario for several months while resolving coverage? If not, the unresolved authorization or exclusion deserves more attention than a small premium saving. This is a budgeting exercise, not a reason to change doses, skip treatment or choose a medication without your prescriber.

Keep the decision file small

Before submitting your election, save these five items together:

• The selected plan name, coverage tier and effective date.
• The applicable drug benefit and exclusion language.
• The current prior authorization and continuation criteria.
• The annual worksheet, with assumptions marked clearly.
• Your enrollment confirmation and the next contact at the prescribing clinic.

Do not rely on a promise that “next year should be better.” Choose using the written benefits available for that year. Our employer coverage guide helps identify who controls the benefit; insurance versus cash-pay math helps compare the treatment costs once the coverage question is answered.