GLP-1 Price Cuts & Medicare Coverage (2026): The Full Guide
Medicare coverage is coming: For the first time, Medicare will cover certain obesity GLP-1s starting mid-2026, with some eligible patients paying as little as $50/month under a new copay cap. In parallel, TrumpRx direct pricing will offer Wegovy and Zepbound starter doses at $350/month. New oral GLP-1 pills are expected at $145/month for people using Medicare, Medicaid, or TrumpRx (pending approvals). If you already use manufacturer discounts (e.g., LillyDirect), expect modest extra savings; compounded options remain available.
The Big Picture
On November 6, 2025, new agreements with Eli Lilly and Novo Nordisk were announced to improve pricing and access for GLP-1 medications. The plan lowers prices starting in 2026, opens Medicare coverage for obesity medications for the first time, and launches TrumpRx—a direct-to-consumer program. The changes affect Medicare, Medicaid, and direct buyers using TrumpRx.
Timeline: When It Happens
- Late 2025: Potential launches of oral GLP-1 pills pending FDA approval—Semaglutide (oral Wegovy) from Novo Nordisk and Orforglipron from Eli Lilly. Price target: $145/month via Medicare, Medicaid, or TrumpRx.
- Early 2026: TrumpRx opens direct pricing for brand GLP-1s. Wegovy and Zepbound starter doses at $350/month. States begin deciding whether Medicaid will opt in.
- Mid-2026: Medicare begins covering certain GLP-1 medications for obesity. Some qualifying patients pay as little as $50/month copay; about 10% of beneficiaries are expected to qualify based on BMI and related conditions.
Pricing Snapshot
- TrumpRx (Wegovy, Zepbound) starter doses: $350/month (direct buyers).
- LillyDirect (Zepbound pens): currently about $299–$449/month for self-pay.
- Medicare pricing: $245/month reference price (what Medicare pays) — eligible patients may pay as little as $50/month out-of-pocket.
- Oral GLP-1s via Medicare/Medicaid/TrumpRx: $145/month (expected 2025–2026, pending approval).
Quick Comparison Table
| Program / Topic | What’s New | Who Qualifies | Starting Price | Start Time |
|---|---|---|---|---|
| Medicare (Part D pilot) | First-ever coverage for obesity meds; capped copays | ~10% of beneficiaries (BMI + comorbidity criteria) | $50/month copay* / Reference price: $245/month | Mid-2026 |
| TrumpRx (DTC portal) | Direct-buy brand GLP-1s at negotiated pricing | Anyone (largest discounts likely with Medicare/Medicaid) | $350/month to start | Early 2026 |
| Oral GLP-1 pills (pending approval) | Upcoming oral options for weight management | Medicare / Medicaid / TrumpRx users | $145/month | Late 2025–2026 |
| Medicaid (state-by-state) | States opt in to get discounted pricing | State Medicaid beneficiaries | Varies (aligned to negotiated prices) | 2026 onward |
*Actual copay may vary based on plan; reference price indicates a negotiated benchmark.
If You’re Thinking of Switching
- Talk to your clinician about dosing equivalence and transition schedules.
- Confirm device format (pen vs vial) and comfort with injections.
- Check eligibility (Medicare criteria, Medicaid state opt-in, TrumpRx account).
- Compare monthly cost after any coupons, discounts, or copay caps.
Telehealth Workflow: What to Expect with Zappy
- Complete a brief intake (history, goals, meds).
- Meet a clinician to discuss options (compounded vs brand-name; oral vs injection).
- We help verify eligibility (Medicare criteria, state Medicaid opt-in, TrumpRx steps) and compare pricing.
- Follow-up to monitor response, side effects, and dose titration.
Safety & Clinical Notes (High-Level)
Who Benefits Most
The 2026 Medicare and Medicaid pricing changes are designed to expand access for individuals who meet specific health and weight criteria. Coverage is targeted rather than universal, focusing on those with the greatest potential health benefit.
Medicare Eligibility Criteria for GLP-1 Coverage
When Medicare begins covering GLP-1 medications for obesity and related conditions in mid-2026, eligibility will extend to roughly 10% of beneficiaries based on specific health factors. Patients will fall into one of three groups:
- Overweight individuals (BMI > 27) who also have prediabetes or cardiovascular disease.
- People with obesity (BMI > 30) who have uncontrolled hypertension, kidney disease, or heart failure.
- Patients with severe obesity (BMI > 35), regardless of other conditions.
These categories reflect a clinical focus on patients with the greatest metabolic and cardiovascular benefit potential, rather than universal weight-loss coverage. The criteria differ from those used for the general population and are meant to guide safe, cost-effective use within Medicare.
Expanded FAQ
Does this include Rybelsus?
The announcements emphasize obesity indications and upcoming oral GLP-1s at $145/month through Medicare/Medicaid/TrumpRx. Rybelsus (oral semaglutide) is approved for type 2 diabetes; whether it’s included under the same direct-buy pricing depends on program details and indication. We’ll update once official guidance clarifies diabetes vs obesity labeling under TrumpRx.
Will commercial insurance change prices right away?
Commercial plans aren’t directly governed by Medicare pricing. Some may mirror or negotiate new rates, but timelines vary by payer. Expect 2026-onward adjustments, not immediate changes.
What about Zepbound vials vs pens?
LillyDirect and some retailers are expanding vial access. It’s not yet confirmed whether TrumpRx pricing explicitly includes vials. We’ll update when the program publishes device-format details.
How do savings cards/coupons interact with TrumpRx?
Manufacturer savings programs typically target commercial insurance or cash-pay scenarios. TrumpRx is a separate direct-price channel; stacking benefits may not be allowed. Use whichever yields the lowest final price.
If I’m already on a discount program, will I save more in 2026?
Probably modestly. Current discount pricing (e.g., LillyDirect pens) is already near the new TrumpRx starter levels, so savings may be small to moderate for many existing cash-pay users.
Are oral GLP-1s right for me?
Orals may appeal if you prefer pills or dislike injections. They’ll target $145/month via Medicare/Medicaid/TrumpRx. Talk to your clinician about efficacy, dosing, and GI tolerance compared with injectables.
Will Medicare cover everyone who wants a GLP-1?
No. Current expectations suggest ~10% of beneficiaries will qualify under defined BMI + comorbidity criteria. Coverage is limited to program rules.
What if my state delays Medicaid opt-in?
Coverage timing could vary. If your state hasn’t opted in, you could still consider TrumpRx direct pricing or existing manufacturer programs while you wait.
Are prices different by dose?
Yes. Programs often publish a “starter” price and scale up by dose. LillyDirect, for example, lists a range for Zepbound pens by dose level.
Can I switch from compounded to brand mid-titration?
It’s possible, but you should confirm an equivalent dose schedule and device training with your clinician to avoid under- or over-dosing.
Do I need prior authorization?
Medicare and many commercial plans often require criteria checks. The Part D pilot will likely have defined rules; expect documentation (BMI, comorbidities, history) to matter.
If I’m not eligible for Medicare coverage, what’s my lowest cash price?
For injectables, TrumpRx’s starter price is $350/month. For orals (pending approval), the target is $145/month for those using Medicare/Medicaid/TrumpRx. Compounded options may be competitive depending on your pharmacy and dose.
Will telehealth prescriptions be honored at TrumpRx?
TrumpRx is intended as a direct-purchase channel; we’ll update as dispensing and e-prescribe workflows are finalized. Zappy supports standard e-prescribing and coordination with participating pharmacies.
Can I use my HSA/FSA?
Typically yes for eligible prescriptions, but always confirm with your plan and keep itemized receipts.
Glossary
- GLP-1: A class of medications that help regulate appetite and glucose.
- TrumpRx: A direct-to-consumer pricing program announced alongside 2026 coverage changes.
- Reference price: A negotiated benchmark price (e.g., $245/month for certain GLP-1s under Medicare context).
- Copay cap: A maximum monthly out-of-pocket amount (e.g., $50 for eligible Medicare patients).
References & Sources
- CNBC – Announcement coverage (Nov 6, 2025)
- The Guardian – Cost cuts & access expansion (Nov 6, 2025)
- Investopedia – Medicare copay & reference price context
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