Open Enrollment: What to Check Before You Choose

This is the part that catches people out, and it is worth stating clearly because national coverage of open enrollment tends to quote the federal calendar as though it were universal.

Twenty-one states plus Washington DC run their own health insurance exchanges rather than using the federal marketplace, and some of them set different dates. A state exchange may open earlier, close later, or use a different cutoff for January coverage.

So do not plan around the federal calendar unless the federal marketplace is the one you actually use. Find your state's marketplace and read its dates directly. That takes about two minutes and it is the difference between enrolling and missing.

Employer open enrollment is a separate thing on a separate schedule. It typically happens in the autumn, but there is no national date — your employer sets it, and the window is often short, sometimes a couple of weeks.

The practical consequence is that the reminder email is the deadline notice, and it is easy to skim. If you get coverage through work, find the dates now rather than waiting to be told twice.

Here is the short list. None of these are hard to look up. All of them are hard to change in March.

Is there a formulary, and what is on it? Every plan that covers prescriptions publishes a formulary — the list of medications it covers and the tier each one sits in. Tiers drive what you pay. Formularies are revised annually, so a medication covered this year is not automatically covered next year, including on a plan you are already on.

What does the plan say about GLP-1 medications specifically? This is the single most variable item in the category. Coverage for this class differs enormously between plans, and plans frequently distinguish between the same medication prescribed for diabetes and prescribed for weight management. Look for the exact wording, not the drug name on a list.

What does prior authorization require? Many plans require documentation before they will cover certain medications, and the criteria are plan-specific — things like documented history, prior attempts at other approaches, or particular clinical measurements. Knowing the criteria before you enroll tells you whether a plan is realistically usable for your situation. What a prior authorization actually asks for covers the mechanics in detail.

How is diagnostic lab work handled? Preventive services and diagnostic testing are treated differently by most plans, and the same blood draw can land in either category depending on why it was ordered. Check whether lab work runs against the deductible, and whether it has to be done at a specific laboratory network.

Is telehealth covered, and from which providers? Plans vary in whether virtual visits are covered on the same terms as in-person, and in which networks they accept.

If you are approaching Medicare eligibility, that is its own calendar. Medicare has separate enrollment periods with separate rules, and the GLP-1 situation there has its own specifics. Medicare and GLP-1s covers that ground.

A formulary tells you whether a medication is on the list and roughly what tier it occupies. It does not tell you whether you personally will be approved for it.

That gap is where most of the frustration in this category lives. A medication can be on the formulary and still require prior authorization, still be denied on first submission, and still be appealable. The list is a necessary condition, not a sufficient one.

Which is why the honest version of this page cannot end with "check the formulary and you will know." Check the formulary, then check the prior-authorization criteria, and understand that the answer for you gets decided case by case.

It is not a promise about coverage. We do not know what your plan covers, we cannot tell you what it will approve, and any page that claims otherwise about a class of medications this volatile is guessing.

What we can say is that the questions above are the right ones, that the window to act on the answers is short, and that going into a year knowing what your plan does is meaningfully better than finding out in March.

If part of your plan for next year involves ongoing clinical care, the weight loss membership page sets out what that looks like here and what it does not depend on your insurance for.