Skip to the page Providence Care & cost guide In this guide Start here Add up the cost Check coverage Find care & ask Read the evidence Pause & check Start with the part on your mind. Keep a few notes for the visit. Providence / check coverage A plain-language care & cost guide # Check what your plan pays for. Start with the name on your insurance card and the exact medicine. Ask about the reason for care as well as the price. Ask the plan to connect these Your health plan Medicine + reason for care Payment approval Your part of the bill Keep the answers beside the offer. ## Rhode Island Medicaid’s announced change ### Ask about the named medicine Give the care service and Medicaid plan the full name. Ask how the change affects the prescription being discussed. Rhode Island’s Medicaid memo, checked September 30, 2026, announces a change beginning October 1, 2026. Medicaid will stop paying for these medicines when they are prescribed solely for weight loss: Semaglutide (Wegovy) Tirzepatide (Zepbound) Liraglutide (Saxenda) Orforglipron (Foundayo) Other uses and younger members If the medicine is for another health condition, the memo requires your care service to send a new payment-approval request to Medicaid. For example, Wegovy has an FDA-approved use to lower heart attack and stroke risk in certain adults with heart disease and excess weight, as of September 2026. Ask the person who orders your medicine whether this use fits your health. Ask Medicaid whether it will pay for that use. Members younger than 21 go through a separate Medicaid review. This memo concerns Medicaid, so it does not settle what a private plan pays. Rhode Island: read the coverage memo ## Medicare: the reason for care matters ### Name the reason on the prescription Call the doctor or other health professional who orders your medicine. Then call the number on your Medicare drug-plan card. Ask whether your usual insurance or the temporary program below could pay, and what records are needed. Under rules checked September 2026, Medicare’s usual prescription insurance, called Part D, does not pay for medicines used only for weight loss. Medicare’s rules allow plans to consider other uses, such as treating type 2 diabetes or lowering heart risk in certain patients, as of September 2026. Type 2 diabetes is a disease that causes high blood sugar. Ask your drug plan whether the exact medicine is covered for the condition named by your doctor. An allowed use does not promise payment. CMS: regular drug coverage rules ## A temporary Medicare route has its own limits ### Ask about the temporary program Ask the doctor or other health professional who orders your medicine to check your health history against the rules below. Ask your Medicare drug plan to confirm whether your type of plan qualifies. CMS is the government agency that runs Medicare. As of September 2026, CMS lists a temporary weight-loss medicine program with a $50 monthly payment for eligible Medicare drug-plan members. Your body makes GLP-1, a signal that affects blood sugar and hunger; GLP-1 drugs copy this signal. This program is called the Medicare GLP-1 Bridge. The program’s start date is July 1, 2026; its end date is December 31, 2027. In 2026, a separate program service handles payment approval and pays pharmacies, instead of your usual Part D insurance. Ask the pharmacy to confirm the program’s approval and the amount you owe before collecting the medicine. You need a prescription and payment approval; the health, age and plan rules below were checked September 2026. Who can qualify The age rule is 18 or older, with no upper age limit. You must have either separate Part D insurance for medicines or Medicare Advantage that manages your medical care and includes prescription insurance. Other Medicare plan types may require a separate Part D plan; ask your plan to check its exact type. Your doctor checks BMI, a number calculated using your weight and height. The program uses the number from when this treatment began. A BMI of 35 or higher can qualify without an added health condition. BMI 30 or higher requires a specific heart failure type, high blood pressure despite treatment, or kidney disease from stage 3a onward. Ask your doctor to match your heart failure diagnosis or kidney disease stage to the program’s rules. For the blood-pressure route, the upper reading must exceed 140 or the lower reading must exceed 90 despite two blood-pressure medicines. A BMI of 27 or higher requires pre-diabetes, a previous stroke or heart attack, or artery disease in the limbs with symptoms. Pre-diabetes means blood sugar above normal but below the level used to diagnose diabetes. Limbs means your arms and legs. Arteries carry blood from the heart. Type 2 diabetes, moderate or severe sleep apnea, and certain liver disease with moderate to advanced scarring rule out this program. With sleep apnea, breathing stops again and again while you sleep. Ask your doctor for the precise diagnosis and, if it is liver disease, the type and amount of scarring. Usual Part D insurance handles these conditions as well as prescriptions meant to lower heart attack or stroke risk. If Part D paid for your GLP-1 medicine in 2026, you cannot use this program in 2026. The prescription must go with ongoing support for eating and physical activity. What the monthly payment means The program’s $50 monthly payment is excluded from the yearly Part D cap on your costs for covered medicines. You still owe the program’s $50 even after reaching that cap. The payment is also excluded from your Part D deductible. A deductible is your required payment before the plan begins paying for costs that fall under that rule. Ask your drug plan how it works. Medicare’s help for people with low incomes does not lower this payment. CMS: program details CMS: who can qualify ## Questions for a workplace or private plan ### Get a clear answer from any plan Is this exact medicine on the covered-drug list? Does the plan cover it for my reason for care? ### Ask what approval means Does the plan need a request before it pays? Who sends it? What will I pay after approval? ### Ask about a refusal What is the written reason? How can I ask the plan to review its decision? Ask the person who orders your medicine to explain the care options. Prior authorization means asking a health plan to agree to payment before a prescription is filled. Take questions to the visit Use these pages to sort out care and costs; the guide operates no clinic and sells no treatment. Start again Read this page as text