THE SHORT ANSWER
Does Medicare Cover Foundayo?
Yes—Medicare Can Now Cover Foundayo for Weight Loss
Since July 1, 2026, people with eligible Part D coverage can get Foundayo for weight loss through the new Medicare GLP-1 Bridge—a flat $50 per monthly fill, covering all Foundayo formulations—if they meet one of CMS's BMI tiers, aren't excluded (Not eligible if you have type 2 diabetes, moderate-to-severe obstructive sleep apnea, or noncirrhotic MASH with moderate-to-advanced liver fibrosis (F2–F3), or if your Part D plan paid for a GLP-1 for you at any time in 2026), and their prescriber gets prior authorization.[29] Basic Part D coverage excludes drugs used for weight loss (some enhanced plans could offer them as supplemental benefits); the Bridge works around that exclusion and runs outside the Part D benefit.[2]
Here's what Medicare coverage for Foundayo looks like today:
- For weight loss: The Medicare GLP-1 Bridge (live since July 1, 2026) covers all Foundayo formulations at $50 per monthly fill for people with eligible Part D coverage (BMI tiers, exclusions + prior authorization); it runs outside your Part D plan
- Your Part D plan: Basic Part D coverage excludes drugs used for weight loss by statute (some enhanced plans could offer them as supplemental benefits)—the Bridge is the pathway, not your plan's formulary
- No carve-out indication: Unlike Zepbound (which may be covered under Part D for moderate-to-severe sleep apnea, subject to the plan's formulary and prior authorization), Foundayo is weight-loss focused—so the $50 Bridge is the main Medicare pathway
Bottom line: Medicare beneficiaries now have a real weight-loss pathway for Foundayo—the $50 Bridge, covering all formulations. Because Foundayo has no separate covered indication (no OSA or cardiovascular analog), the Bridge is the primary way Medicare covers it.
For a complete overview of getting Foundayo covered regardless of insurance type, see our full coverage guide.
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THE WEIGHT-LOSS PATHWAY (LIVE SINCE JULY 1, 2026)
The $50 Medicare GLP-1 Bridge
The Medicare GLP-1 Bridge is a CMS demonstration that launched July 1, 2026 and runs through December 31, 2027. Running outside the Part D benefit, it is the now-live way for people with eligible Part D coverage to get a weight-loss GLP-1—including Foundayo—for a flat copay.[29]
What the Bridge Covers for Foundayo
- $50 flat monthly copay—the same regardless of dose or your Part D benefit phase[29]
- All Foundayo formulations covered. Unlike Zepbound (KwikPen only), every Foundayo formulation is covered under the Bridge[32]
- Weight-loss indication. The Bridge covers Foundayo prescribed for weight reduction and maintenance (with ongoing lifestyle modification)
- Eligibility uses BMI tiers, CMS's exclusions and your plan type. Part D plans and pharmacies don’t opt in, and you don’t enroll separately; your prescriber must get prior authorization.
What the $50 Doesn't Count Toward (The 3 Catches)
The Bridge copay is collected at the pharmacy, but watch for three things:
- It does not apply to your Part D deductible
- It does not count toward your annual out-of-pocket cap
- Extra Help / LIS doesn't reduce it—even beneficiaries who normally pay only a few dollars per prescription pay the full $50[29]
Full Bridge Guide: Eligibility, Cost & How to Apply
For the complete BMI tiers and qualifying conditions, plan-type eligibility, the cost catches, and the step-by-step prior authorization process, see our dedicated Medicare GLP-1 Bridge guide.
Quick things to check for Foundayo: that you meet one of the Bridge's BMI tiers (a BMI ≥35 qualifies on its own; a BMI ≥30 or ≥27 qualifies only with specific conditions), that none of the exclusions apply (Not eligible if you have type 2 diabetes, moderate-to-severe obstructive sleep apnea, or noncirrhotic MASH with moderate-to-advanced liver fibrosis (F2–F3), or if your Part D plan paid for a GLP-1 for you at any time in 2026), and that your plan type is eligible. The Bridge guide walks through each.
Bridge vs. the Permanent BALANCE Model
The Bridge is a temporary program (through Dec 31, 2027). The separate, permanent BALANCE Model that would have built weight-loss GLP-1 coverage into Part D is delayed, with no new start date—on April 21, 2026, CMS declined to implement it in Part D for 2027 and extended the Bridge instead.[28] Coverage after the Bridge ends is currently undetermined—there is no confirmed successor program.
AN ORAL SMALL-MOLECULE GLP-1
What Is Foundayo?
Foundayo (orforglipron) is Eli Lilly's oral GLP-1 medication for chronic weight management, FDA-approved on April 1, 2026. It's an oral small-molecule (non-peptide) GLP-1 receptor agonist—a daily pill, no injections. Lilly describes it as the only GLP-1 pill for weight loss that can be taken any time of day without food or water restrictions (Lilly).
No Food or Water Timing Restrictions
Because orforglipron is a small molecule (not a peptide), it can be taken any time of day, with or without food or water. This is a meaningful contrast with oral semaglutide, which must be taken on an empty stomach with no more than 4 ounces of water and a 30-minute wait before eating, drinking or taking other oral medicines.
As a newly approved medication, Foundayo is a first-mover—little patient-facing coverage information exists yet, which is why this Medicare guide focuses on the one pathway that's live today: the $50 GLP-1 Bridge.
WHY THE BRIDGE EXISTS
Part D & the Weight-Loss Exclusion
The reason Foundayo's weight-loss coverage runs through the $50 Bridge—rather than your regular Part D plan—is a long-standing federal law. Unlike commercial insurance that can choose whether to cover weight loss medications, the exclusion from basic Part D coverage is mandated by federal law (some enhanced plans could offer weight-loss drugs as supplemental benefits). The Bridge is a CMS demonstration that works around that exclusion for now; outside the Bridge, the exclusion still applies.
The Statutory Exclusion
42 U.S.C. § 1395w-102(e)(2)(A) cross-references the Medicaid exclusion at 42 U.S.C. § 1396r-8(d)(2), which prohibits coverage of "agents when used for anorexia, weight loss, or weight gain."[2]
This law was enacted as part of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 and remains in effect today.
What This Means for You
| Pathway | Coverage | Reason |
|---|---|---|
| Basic Part D (your plan) | Not Covered | Drugs used for weight loss excluded from basic Part D coverage by 42 U.S.C. § 1395w-102 |
| $50 GLP-1 Bridge (live July 1, 2026) | Covered, with conditions | $50 per monthly fill copay; all Foundayo formulations; runs outside Part D; eligible Part D coverage + BMI tiers + exclusions + PA |
How the Weight-Loss Pathway Opened Up
🗓️ From Announcement to Live Program
On November 6, 2025, the Trump administration announced agreements with Eli Lilly and Novo Nordisk to expand Medicare coverage of GLP-1 medications for obesity.[3][21][22]
That coverage is now live. The Medicare GLP-1 Bridge launched July 1, 2026, giving eligible Part D beneficiaries Foundayo for $50 per monthly fill.[29]
See the $50 GLP-1 Bridge section above for what's covered today, and the note below for the separate BALANCE Model (delayed in Part D, with no new start date).
Who Is Eligible
The live Bridge uses BMI tiers: a BMI of ≥35 qualifies on its own, while a BMI ≥30 or ≥27 qualifies only with specific qualifying conditions (Age 18+ and BMI ≥35; or BMI ≥30 with HFpEF, uncontrolled high blood pressure or CKD stage 3a+; or BMI ≥27 with prediabetes, a prior heart attack or stroke, or symptomatic PAD). Not eligible if you have type 2 diabetes, moderate-to-severe obstructive sleep apnea, or noncirrhotic MASH with moderate-to-advanced liver fibrosis (F2–F3), or if your Part D plan paid for a GLP-1 for you at any time in 2026. See the full Bridge guide for the exact tiers and conditions.[29]
What You'll Pay
| Scenario | Monthly Cost |
|---|---|
| What you pay (Bridge beneficiary copay) | $50 per monthly fill[29] |
Behind the scenes: participating manufacturers provide Bridge drugs at a net program price of $245 per monthly supply, and the pharmacy is paid the wholesale acquisition cost minus your $50 copay, plus a $3 dispensing fee ($5 in long-term care) and any applicable sales tax. Eligible beneficiaries pay only the $50 per monthly fill copay—not that amount. Note the $50 does not count toward your deductible or out-of-pocket cap, and Extra Help doesn't reduce it.
How We Got Here: The Timeline
| Date | What Happened |
|---|---|
| November 6, 2025 | White House announces Medicare GLP-1 coverage agreements with Lilly and Novo Nordisk[3] |
| December 23, 2025 | CMS announces the BALANCE Model as the planned permanent framework[28] |
| April 1, 2026 | FDA approves Foundayo (orforglipron) for chronic weight management |
| April 21, 2026 | CMS declines to implement BALANCE in Part D for 2027; extends the GLP-1 Bridge instead[28] |
| July 1, 2026 ✅ LIVE | Medicare GLP-1 Bridge launches—$50 per monthly fill, all Foundayo formulations[29] |
| December 31, 2027 | Scheduled end of the Bridge; coverage afterward is undetermined[29] |
What About the Permanent BALANCE Model?
BALANCE in Part D Is Delayed, With No New Start Date
The BALANCE Model (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth) was the planned permanent framework to waive the Part D weight-loss exclusion for Part D plans that joined it.[30] On April 21, 2026, CMS declined to implement it in Part D for 2027 and extended the temporary GLP-1 Bridge through Dec 31, 2027 instead.[28] The Bridge—not BALANCE—is the live weight-loss pathway today, and no successor program is confirmed.
TrumpRx: Direct-Purchase Option
Don't Qualify for the Bridge?
TrumpRx.gov (launched February 5, 2026) lists manufacturers’ direct-purchase prices—available to anyone, including Medicare beneficiaries who don't meet Bridge eligibility:[21]
- Who can use it: Anyone (not limited to Medicare/Medicaid)
- Price: TrumpRx lists the manufacturers’ own self-pay prices (not a separate, cheaper price). Foundayo orders go through LillyDirect, at $149–$299/month by dose
Your Pathways Today
If you're a Medicare beneficiary who wants Foundayo, here's where coverage stands now:
- Weight loss: The $50 GLP-1 Bridge (all Foundayo formulations)—Part D plans and pharmacies don’t opt in, and you don’t enroll separately; your prescriber must get prior authorization
- TrumpRx: Direct-purchase via TrumpRx.gov (same LillyDirect self-pay prices)
- Self-pay: See our cost guide for other options
COVERAGE VARIES BY PLAN
Medicare Advantage Plans
Medicare Advantage (Part C) plans with prescription drug coverage (MA-PD) follow the same federal exclusion for weight loss drugs as standalone Part D. The good news: the $50 GLP-1 Bridge runs through a single central processor—not your individual plan—so your plan doesn't have to opt in or add Foundayo to its formulary for you to get Bridge coverage.[29]
| Plan Type | Basic Part D (Weight Loss) | $50 GLP-1 Bridge | Notes |
|---|---|---|---|
| Original Medicare + Part D | Not Covered | Eligible plan type (CMS criteria + PA apply) | Bridge covers all Foundayo formulations at $50/mo |
| Medicare Advantage (HMO) | Not Covered | Eligible plan type (CMS criteria + PA apply) | MA-PD beneficiaries can use the Bridge if they meet CMS's criteria; plans don't opt in |
| Medicare Advantage (PPO) | Not Covered | Eligible plan type (CMS criteria + PA apply) | MA-PD beneficiaries can use the Bridge if they meet CMS's criteria; plans don't opt in |
| Medicare Supplement (Medigap) | Does not cover prescription drugs—you need separate Part D (and a Part D plan is required to use the Bridge) | ||
What to Know About MA Plans
- Bridge isn't plan-dependent: For weight-loss coverage of Foundayo, the $50 Bridge works with standalone Part D and MA-PD plans alike (not if your only Medicare coverage is a special plan type such as private fee-for-service, a cost plan or PACE)
- You must be enrolled in Part D: The Bridge requires existing Part D (or MA-PD) enrollment for CY2026—see the Bridge guide for eligible plan types
- Out-of-pocket limits: An MA plan's yearly out-of-pocket maximum covers medical (Part A and B) services, not prescription drugs; the $50 Bridge copay doesn't count toward it or toward the Part D cap
Open Enrollment Consideration
Because the $50 Bridge isn't tied to your specific plan's formulary, you generally don't need to switch plans to get Foundayo for weight loss. The Annual Enrollment Period (October 15 - December 7) is still worth reviewing for your overall Part D costs. Learn more at Medicare.gov enrollment periods.
WHAT YOU'LL PAY
Cost & Alternatives for Medicare Beneficiaries
Savings Card Not Available for Medicare
Medicare beneficiaries cannot use the Foundayo Savings Card. Federal law prohibits manufacturer copay assistance for government insurance programs including Medicare, Medicaid, TRICARE, and VA benefits.[17]
The savings card (as little as $25 a month for commercially insured patients whose plan covers Foundayo) is not an option if you have any Medicare coverage.
What the $50 Bridge Copay Means for Your Part D Costs
The Bridge copay is a flat $50 per monthly fill, but it behaves differently from a normal Part D drug cost—here's how it interacts with the rest of your Part D spending:
- The $50 sits outside Part D: It does not count toward your Part D deductible or your annual out-of-pocket cap, and Extra Help / LIS doesn't reduce it[29]
- 2026 Part D Out-of-Pocket Cap: Your other Part D drugs are still subject to the $2,100 annual out-of-pocket maximum for 2026 (up from $2,000 in 2025)[18]
- 2026 Part D Deductible: Maximum deductible is $615 for 2026 (up from $590 in 2025), and applies to your regular covered drugs—not the Bridge copay[26]
- Same price every month: The $50 is the same regardless of dose or which Part D benefit phase you're in
Extra Help (Low Income Subsidy)
If you have limited income and resources, you may qualify for Extra Help, which significantly reduces Part D costs:
| 2026 Limits | Individual | Married Couple |
|---|---|---|
| Income Limit | up to 150% of the federal poverty level | up to 150% of the federal poverty level |
| Resource Limit | $18,090 | $36,100 |
With Extra Help, copays are at most $5.10 for generics and $12.65 for brand-name drugs (2026). Extra Help does not lower the $50 Bridge copay. Apply at ssa.gov/medicare/part-d-extra-help.[19]
Mounjaro for Type 2 Diabetes (Different Medication)
Important: Mounjaro is a Different Drug
If you have Type 2 Diabetes: Mounjaro (tirzepatide) may be covered under Medicare Part D for T2D, subject to your plan's formulary, prior authorization and exceptions process (people with type 2 diabetes can't use the Bridge). However, Mounjaro is a completely different medication from Foundayo (orforglipron)—different molecule, different mechanism (dual GIP/GLP-1 vs GLP-1 only), and different administration (injection vs pill). Many patients experience significant weight loss on Mounjaro. Ask your doctor if this option makes sense for your diabetes management.[20]
Lilly Cares Patient Assistance
Eli Lilly's patient assistance program (Lilly Cares) provides free medications to eligible patients, including some Medicare Part D beneficiaries. But Zepbound, Mounjaro and Foundayo are not on Lilly Cares’ medication list, so it is not a route to free Foundayo.
Instead: LillyDirect offers cash-pay pricing from $149/month—no insurance needed. See our complete cost guide for all options.
STEP-BY-STEP GUIDE
How to Check Your MA Plan's Formulary
For weight-loss coverage of Foundayo, the $50 Bridge—not your plan's formulary—is the pathway, and your prescriber handles the prior authorization. Still, it's worth confirming how your plan lists Foundayo (for example, if you later switch to a covered indication). Here's how to check:
Visit Medicare.gov Plan Finder
Go to Medicare.gov Plan Compare and enter your ZIP code. You can search for plans or look up your current plan.
Add Foundayo to Your Drug List
In the drug search, enter "Foundayo" or "orforglipron." The tool will show if and how the drug is covered on different plans.
Check for Coverage Notes
Your standard plan won't list Foundayo as covered for weight loss—that's expected. For weight loss, coverage comes through the $50 GLP-1 Bridge, which runs separately from your plan's formulary.
Contact Your Plan Directly
Formularies can change, and the Plan Finder may not reflect the most current coverage. Call your plan's member services to confirm.
Call Script for Medicare Plan
"Hi, I'm calling to check coverage for a prescription medication. My Medicare ID is [NUMBER]. I need to know:
- Is my plan a standalone Part D plan or a Medicare Advantage plan with drug coverage?
- How is Foundayo listed on my plan's formulary?
- Has this plan paid for any GLP-1 drug for me this year?
- Can you send me the coverage criteria in writing?"
Your plan doesn't process Bridge claims (CMS uses a central processor), so it can't approve the Bridge for you. Your prescriber submits the Bridge prior authorization; the $50 copay doesn't count toward your deductible or out-of-pocket cap.
Pro tip: Request coverage criteria in writing and keep records of all calls, including the date, time, and representative's name.
APPEAL PROCESS
What to Do If Medicare Denies Foundayo
Bridge Denials Can't Be Appealed
For Foundayo for weight loss, the decision comes from the Bridge, not your Part D plan: No appeals process for a Bridge prior-authorization denial: your prescriber can resubmit with more information (Part D appeal rights for Part D coverage decisions still apply). Basic Part D coverage excludes drugs used for weight loss, and the Bridge runs outside your Part D plan, so a plan appeal isn't the route for a Bridge decision. The appeal steps below apply only to other decisions your Part D plan makes.
Medicare Appeals Have High Success Rates
Over 80% of Medicare Advantage prior authorization appeals succeed—yet only about 11% of patients ever appeal, according to KFF analysis of CMS data.[6] If you're denied, don't give up.
Medicare Appeal Timeline
| Appeal Level | Filing Deadline | Decision Timeline | Notes |
|---|---|---|---|
| 1. Redetermination | Within 65 days from the date on the denial notice | 7 days (72 hrs if expedited) | Reviewed by plan, not original reviewer |
| 2. Reconsideration | Within 60 days after you receive the redetermination decision | 7 days (72 hrs if expedited) | Independent review by the IRE (Independent Review Entity) |
| 3. ALJ Hearing | 60 days from reconsideration | 90 days | Requires $200+ amount in controversy (2026)[7] |
| 4. Medicare Appeals Council | 60 days from ALJ | 90 days | Reviews ALJ decision |
| 5. Federal District Court | 60 days from Council | Varies | Requires $1,960+ amount in controversy (2026)[7] |
How to Appeal a Medicare Denial
Get the Denial in Writing
Request a Coverage Determination Notice with the specific reason for denial. Common reasons include:
- "Not medically necessary"
- "Does not meet plan criteria"
- "Documentation insufficient"
- "Drug not on formulary for this indication"
Gather Supporting Documentation
If your prescriber resubmits a Bridge prior authorization, work with them to compile:
- BMI documentation showing which Bridge tier you meet (Age 18+ and BMI ≥35; or BMI ≥30 with HFpEF, uncontrolled high blood pressure or CKD stage 3a+; or BMI ≥27 with prediabetes, a prior heart attack or stroke, or symptomatic PAD)
- Records of the qualifying condition, if your tier needs one (for example, prediabetes or high blood pressure)
- Confirmation that none of the Bridge exclusions apply (Not eligible if you have type 2 diabetes, moderate-to-severe obstructive sleep apnea, or noncirrhotic MASH with moderate-to-advanced liver fibrosis (F2–F3), or if your Part D plan paid for a GLP-1 for you at any time in 2026)
- Notes showing Foundayo is prescribed for weight reduction or maintenance with lifestyle changes
File Redetermination Request
Submit your appeal to your Medicare plan within 65 days from the date on the denial notice. Include all supporting documentation and a cover letter addressing the specific denial reason.
Escalate If Necessary
If redetermination is denied, request Reconsideration by an independent Independent Review Entity (IRE). This is an entirely new review not influenced by the plan.
For detailed appeal strategies, see our complete Foundayo appeals guide.
MEDICARE FOUNDAYO COVERAGE
Frequently Asked Questions
Yes, with conditions—since July 1, 2026. Basic Part D coverage excludes drugs used for weight loss (some enhanced plans could offer them as supplemental benefits), but the separate $50 Medicare GLP-1 Bridge is now live and covers all Foundayo formulations for weight loss at a flat $50/month for people with eligible Part D coverage. It runs outside the Part D benefit.
Eligibility is BMI-based (a BMI ≥35 qualifies on its own; a BMI ≥30 or ≥27 qualifies only with specific conditions) and requires prescriber prior authorization. Not eligible if you have type 2 diabetes, moderate-to-severe obstructive sleep apnea, or noncirrhotic MASH with moderate-to-advanced liver fibrosis (F2–F3), or if your Part D plan paid for a GLP-1 for you at any time in 2026. Part D plans and pharmacies don’t opt in, and you don’t enroll separately; your prescriber must get prior authorization.
Through the Medicare GLP-1 Bridge, eligible beneficiaries pay a flat $50/month for Foundayo, regardless of dose. One catch: the $50 does not count toward your Part D deductible or your annual out-of-pocket cap, and Extra Help / LIS doesn't reduce it—even beneficiaries who normally pay only a few dollars per prescription pay the full $50. The Bridge runs through December 31, 2027. See our full Medicare GLP-1 Bridge guide for eligibility and how to apply.
Yes. The Medicare GLP-1 Bridge covers all formulations of Foundayo. This differs from Zepbound, where the Bridge covers only the KwikPen (not single-dose vials or pens). Foundayo (orforglipron) is marketed as an oral tablet.
Foundayo (orforglipron) is Eli Lilly's oral GLP-1 medication for chronic weight management, FDA-approved on April 1, 2026. It's an oral small-molecule (non-peptide) GLP-1—a daily pill, no injections. Because it's a small molecule rather than a peptide, it can be taken any time of day, with or without food or water—unlike oral semaglutide, which must be taken on an empty stomach with a 30-minute wait before eating.
It depends on your BMI. Under the $50 GLP-1 Bridge, a BMI of ≥35 qualifies on its own—no additional condition required. A BMI of ≥30 or ≥27 qualifies only with specific conditions (the exact tiers and conditions are on our Bridge guide). Unlike Zepbound, Foundayo has no separate covered indication like sleep apnea, so the Bridge is the primary Medicare pathway. Whatever your BMI, you can't use the Bridge if you have type 2 diabetes, moderate-to-severe obstructive sleep apnea, or noncirrhotic MASH with moderate-to-advanced liver fibrosis (F2–F3), or if your Part D plan paid for a GLP-1 for you at any time in 2026.
For weight loss, it doesn't matter much: the $50 GLP-1 Bridge runs through a single central processor, not your individual plan, so both Original Medicare + Part D and Medicare Advantage (MA-PD) beneficiaries can use it—your plan doesn't have to opt in or add Foundayo to its formulary. You do need to be enrolled in Part D (or MA-PD) for 2026. See the Bridge guide for eligible plan types.
For weight loss, Foundayo is covered through the Medicare GLP-1 Bridge, and there is no appeals process for a Bridge prior-authorization denial: your prescriber can resubmit with more information (Part D appeal rights for Part D coverage decisions still apply). Ask your prescriber to resubmit with your BMI documentation, any qualifying-condition records, and confirmation that no exclusion applies. Basic Part D coverage excludes drugs used for weight loss, and the Bridge runs outside your Part D plan, so a plan appeal isn't the route for a Bridge decision. For other Part D plan decisions, the usual Medicare drug appeals apply: a Redetermination within 65 days from the date on the denial notice, then an independent review within 60 days after you receive the redetermination decision.
YOUR PATH FORWARD
What's Next
Foundayo Coverage: Other Insurance Options
Coverage varies significantly by program type. See our guides:
- Medicaid — Coverage varies by state (verify with your state program)
- UnitedHealthcare — Medicare Advantage: weight loss through the Bridge; commercial coverage depends on your plan
- Aetna — Commercial coverage depends on your plan
- BCBS — Coverage varies by regional plan
- Cigna — Prior authorization typically required
Other GLP-1 Medications on Medicare
Medicare coverage varies by medication. Compare your options:
References
- CMS. (2025). "BALANCE (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth) Model." cms.gov
- Medicare Prescription Drug, Improvement, and Modernization Act of 2003. 42 U.S.C. § 1395w-102(e)(2)(A). law.cornell.edu
- White House. (November 6, 2025). "Fact Sheet: President Donald J. Trump Announces Major Developments in Bringing Most Favored Nation Pricing to American Patients." whitehouse.gov
- FDA. (December 20, 2024). "FDA Approves First Medication for Obstructive Sleep Apnea." fda.gov
- Medicare Interactive / NCOA. (2025). "Maximum out-of-pocket limit." 2025 Medicare Advantage MOOP: $9,350 in-network. medicareinteractive.org; ncoa.org
- Kaiser Family Foundation (KFF). (2024). "Medicare Advantage Insurers Made Nearly 50 Million Prior Authorization Determinations in 2023." Analysis of CMS data: 83.2% of appeals partially or fully overturned in 2022; only 11% of denials appealed. kff.org; See also: AMA commentary at ama-assn.org
- CMS. (2025). "Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for Calendar Year 2026." Federal Register, December 4, 2025. 2026 thresholds: $200 for ALJ, $1,960 for Federal Court. federalregister.gov
- Wellcare. (2025). "Does Medicare Cover Weight-Loss Drugs? Understanding GLP-1 Coverage." wellcare.com
- ASPE/HHS. (2024). "Medicare Coverage of Anti-Obesity Medications." aspe.hhs.gov
- Georgetown Medicare Policy Initiative. (April 2025). "Policy options to cover anti-obesity drugs." georgetown.edu
- Medicare.gov. (2025). "Filing an appeal." medicare.gov
- Congressional Research Service. (2024). "Medicare Coverage of GLP-1 Drugs." IF12758. congress.gov
- Hernandez I, et al. (2024). "Medicare Part D Coverage of Anti-obesity Medications: A Call for Policy Change." JAMA Internal Medicine. pubmed.ncbi.nlm.nih.gov
- JAMA. (January 2025). "FDA Approves Tirzepatide (Zepbound) as First Drug for Obstructive Sleep Apnea." Note: This is Zepbound, not Foundayo. jamanetwork.com
- CDC. (2024). "New Adult Obesity ICD-10-CM Codes." Codes E66.811, E66.812, E66.813 effective October 1, 2024. cdc.gov
- Malhotra A, et al. (2024). "Tirzepatide for the Treatment of Obstructive Sleep Apnea and Obesity." N Engl J Med. 2024;391:1193-1205. Note: This study is about Zepbound (tirzepatide), not Foundayo (orforglipron). nejm.org
- Eli Lilly. (2026). "Foundayo Full Terms and Conditions." Excludes Medicare, Medicaid, TRICARE, VA, and other government programs. lilly.com
- CMS. (2026). "Announcement of Calendar Year (CY) 2027 Medicare Advantage Capitation Rates and Part C and Part D Payment Policies," Table V-2 (Part D deductible and out-of-pocket threshold, 2026 and 2027). cms.gov
- Social Security Administration. "Extra Help with Medicare Prescription Drug Costs" (how to apply). 2026 resource limits and copays: CMS, "CY 2026 Resource and Cost-Sharing Limits for Low-Income Subsidy (LIS)," October 31, 2025. ssa.gov
- CRS. (2024). Medicare Coverage of GLP-1 Drugs. IF12758. "Medicare allows coverage through Part D plans for GLP-1 drugs that the FDA has approved for T2DM and CVD." congress.gov
- NCPA. (November 11, 2025). "About the Trump, Eli Lilly, Novo Nordisk deals on GLP-1 prices." ncpa.org
- Axios. (November 6, 2025). "Trump announces Medicare coverage of weight-loss drugs." axios.com
- AARP. (November 2025). "When Will the Cost of GLP-1 Weight Loss Drugs Go Down?" aarp.org
- STAT News. (November 25, 2025). "Trump administration unveils new round of Medicare-negotiated drug prices." statnews.com
- CBS News. (November 6, 2025). "Trump announces deal to lower weight loss drug prices in some cases." cbsnews.com
- Medicare.gov. (2026). "How much does Medicare drug coverage cost?" 2026 Part D deductible: $615; OOP cap: $2,100. medicare.gov
- Sleep Foundation. (December 2025). "Does Medicare Cover GLP-1s for Sleep Apnea?" Note: Foundayo is not FDA-approved for OSA—only Zepbound (tirzepatide) has that indication. sleepfoundation.org
- CMS. (December 23, 2025). "BALANCE (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth) Model." Announced as the planned permanent framework; on April 21, 2026 CMS declined to implement it in Part D for 2027 and extended the GLP-1 Bridge through Dec 31, 2027 instead. cms.gov
- CMS. (2026). "Coming Soon: $50 Monthly GLP-1 Access for Medicare Beneficiaries" / Medicare GLP-1 Bridge — Information for Prescribers and Beneficiaries. Bridge live July 1, 2026–December 31, 2027; $50 flat monthly copay (does not count toward deductible or OOP cap; LIS does not apply); BMI-based eligibility with prescriber prior authorization. cms.gov
- Mintz. (January 5, 2026). "The BALANCE Model and a New Wave of CMS Drug Pricing Models." BALANCE waives Part D weight-loss exclusion. mintz.com
- Kiplinger. (January 5, 2026). "9 Medicare Changes to Watch in 2026." 2026 MA OOP limit: $9,250 in-network. kiplinger.com
- CMS. (June 2026). "Medicare GLP-1 Bridge — Information for Pharmacies." Covered drugs and forms: Wegovy (injection and tablets), Foundayo, and Zepbound KwikPen only—single-dose vials and single-dose pens not covered. cms.gov
Disclaimer
The information on this page is for educational and informational purposes only and is not intended as medical advice. Honest Care does not provide medical diagnosis, treatment, or individualized recommendations. Always seek the advice of your physician or other qualified healthcare professional regarding any medical condition or treatment.
While this content has been reviewed for accuracy and balance, new evidence may emerge after publication. Drug availability, indications, and insurance coverage can change over time. Honest Care makes no warranties as to completeness or currentness of the information and is not responsible for decisions made based on this content.