SilverScript does not cover Wegovy when it is prescribed for weight loss, because federal law bars every Medicare Part D plan from paying for drugs used for weight management. There are two ways a SilverScript member may still get Wegovy at a manageable cost: the plan may cover it when a doctor prescribes it to reduce cardiovascular risk in a patient with heart disease, and a separate Medicare demonstration program that began July 1, 2026 offers Wegovy for a flat $50 a month to beneficiaries who meet its clinical criteria.
Why Part D Can’t Pay for Wegovy as a Weight-Loss Drug
The Social Security Act excludes drugs “used for weight loss” from Part D coverage. The exclusion is still in force in 2026. CMS proposed a rule in late 2024 that would have reinterpreted the statute to allow coverage for obesity treatment, but the agency dropped that provision from its final 2026 rule without explanation.1Healio. CMS Decision to Remove Obesity Drug Coverage From 2026 Final Rule Disappoints Societies Bills such as the Treat and Reduce Obesity Act have been introduced repeatedly but have never passed either chamber.
So if your prescription is written only for weight loss, SilverScript cannot pay for it. Neither can any other Part D plan.
When SilverScript May Cover Wegovy: The Cardiovascular Indication
On March 8, 2024, the FDA approved Wegovy for a second use: reducing the risk of heart attack, stroke, and cardiovascular death in adults with established cardiovascular disease who are overweight or obese.2AJMC. FDA Approves Semaglutide to Prevent Heart Events in Patients With CVD and Excess Weight CMS followed with guidance that Part D plans may add Wegovy to their formularies for this indication, because it now qualifies as a medically accepted use that falls outside the weight-loss exclusion.3KFF. A New Use for Wegovy Opens the Door to Medicare Coverage for Millions of People With Obesity
Plans are permitted to cover it, not required to. Each plan decides whether to list the drug and whether to apply prior authorization, step therapy, or quantity limits.4NPR. Wegovy Medicare Part D Weight Loss Drugs One third-party prescriber database lists SilverScript as covering Wegovy under its Medicare prescription drug plan with no prior authorization, no step therapy, and no quantity limit, though that listing does not specify formulary tier or confirm coverage across every SilverScript plan variant.5PrescriberPoint. Wegovy Coverage SilverScript Because coverage can change year to year and differs by plan, confirm the current year’s formulary by calling member services or checking the plan documents before you fill the prescription.
What You Would Pay if SilverScript Covers It
SilverScript offers three Part D plans: SmartSaver, Choice, and Plus. Each uses a five-tier formulary that ranges from preferred generics up to specialty drugs.6Oak Street Health. What Is SilverScript Wegovy carries a wholesale acquisition cost of $1,349 per package, so if it appears on a plan’s formulary it will likely sit on Tier 4 or Tier 5, where cost sharing is coinsurance rather than a flat copay.7Novo Nordisk Pricing. Wegovy Pricing Specialty-tier coinsurance generally runs 25 to 33 percent of the drug’s cost.3KFF. A New Use for Wegovy Opens the Door to Medicare Coverage for Millions of People With Obesity
The Inflation Reduction Act caps Part D out-of-pocket spending at $2,000 in 2025 and $2,100 in 2026.8KFF. Explaining the Prescription Drug Provisions in the Inflation Reduction Act Once you reach the cap, your plan pays the rest for the year. You can also enroll in the Medicare Prescription Payment Plan to spread that amount into monthly installments rather than paying it at the pharmacy counter.9JAMA Health Forum. Medicare Prescription Payment Plan
The $50 Monthly Option: The Medicare GLP-1 Bridge
On July 1, 2026, CMS launched the Medicare GLP-1 Bridge, a demonstration program that gives qualifying beneficiaries access to Wegovy (both injection and tablet forms), Zepbound, and Foundayo for a flat $50 monthly copay.10CMS. CMS to Provide $50 Monthly Access to GLP-1 Medications for Medicare Beneficiaries The program was originally set to end December 31, 2026, but CMS extended it through December 31, 2027 after delaying a planned successor program.11AHA. CMS Delays Part D Portion of BALANCE Model Expansion of GLP-1 Access
The Bridge sits outside standard Part D. SilverScript does not process these claims or carry the risk; Humana handles prior authorizations, claims, and pharmacy payments on behalf of CMS.12CMS. Medicare GLP-1 Bridge Your prescriber submits a prior authorization attesting that you meet the clinical criteria, and the pharmacy bills the Bridge using a dedicated BIN and processor control number.
You must meet all of the following to qualify:13Medicare.gov. Medicare GLP-1 Bridge: GLP-1 Drugs for $50 a Month
- Enrollment in a standalone Part D plan (such as SilverScript) or a Medicare Advantage plan with drug coverage.
- No GLP-1 drug already paid for by your current plan. If SilverScript covers Wegovy for you under the cardiovascular indication, you continue using that benefit instead.
- No type 2 diabetes, moderate-to-severe sleep apnea, or fatty liver disease.
- Age 18 or older, meeting one of three clinical tiers: BMI of 35 or higher; BMI of 30 or higher with heart failure, hard-to-control high blood pressure, or chronic kidney disease (stage 3a or above); or BMI of 27 or higher with prediabetes or a history of heart attack, stroke, or blocked arteries.
A few boundaries matter. The $50 copay does not count toward your Part D deductible or your annual out-of-pocket maximum, and the Extra Help low-income subsidy cannot reduce it.14Medicare.gov. Weight Loss Drugs The Bridge covers Wegovy for weight reduction only; if your doctor is prescribing it for cardiovascular risk reduction, that use is excluded from the Bridge and routed through standard Part D instead.12CMS. Medicare GLP-1 Bridge
If SilverScript Denies Coverage
When SilverScript does not list Wegovy on its formulary for the cardiovascular indication, or denies a claim, you can request a coverage determination or formulary exception. Your prescriber submits a supporting statement explaining why Wegovy is medically necessary and why formulary alternatives would be less effective or cause adverse effects.15CMS. Medicare Part D Exceptions Once SilverScript has that statement, it must issue a standard decision within 72 hours, or 24 hours for an expedited request when a delay could seriously harm your health.16CMS. Medicare Part D Coverage Determinations
If the plan says no, the appeal path is structured and the deadlines are federal:
- Redetermination with the plan, filed within 65 days of the denial. The plan has 7 calendar days to respond to a standard appeal or 72 hours for an expedited one.17eCFR. 42 CFR Part 423, Subpart M
- Review by an Independent Review Entity if the plan upholds its denial.
- A hearing before an Administrative Law Judge if the independent reviewer also denies coverage.18CMS. Medicare Part D Appeals and Grievances Forms
Paying Out of Pocket
If none of these routes works, the self-pay price depends on how you buy the drug. The wholesale acquisition cost is $1,349 per package.7Novo Nordisk Pricing. Wegovy Pricing Novo Nordisk sells Wegovy directly for $149 per month at the 1.5 mg and 4 mg doses, and $199 per month for the introductory 0.25 mg and 0.5 mg doses, rising to $349 after two fills.19Wegovy.com. What to Pay for Wegovy One caution for Medicare members: the TrumpRx.gov discount program explicitly excludes people enrolled in Medicare, Medicare Part D, or Medicare Advantage prescription drug plans from using its coupons.20TrumpRx. Wegovy Anything you pay through a self-pay channel does not count toward your Part D deductible or out-of-pocket maximum.
Novo Nordisk has announced that effective January 1, 2027, the Wegovy list price will drop to $675 per month for maintenance doses, roughly a 50 percent reduction.21PR Newswire. Novo Nordisk Announces Significant Reduction in US List Price for Wegovy, Ozempic, and Rybelsus Until Congress repeals the weight-loss exclusion or a new Medicare model takes effect, SilverScript’s standard Part D benefit cannot cover Wegovy for weight loss, and the Bridge program is the main pathway for members who need it for that reason.22Medicare Rights Center. GLP-1 Weight Loss Drug Demonstration Begins July 2026