Does Medicare Cover Foundayo? Eligibility, Costs, and Bridge Program

Yes, Medicare covers Foundayo, but only through a temporary program and only if you qualify. Beginning July 1, 2026, Medicare Part D beneficiaries who meet specific weight and health criteria can fill a monthly prescription for Foundayo for a flat $50 copay through the Medicare GLP-1 Bridge, a nationwide demonstration that runs through December 31, 2027.¹

Why Coverage Runs Through a Separate Program

Federal law bars standard Medicare Part D from covering drugs prescribed solely for weight loss. Rather than wait for Congress to change the statute, the Centers for Medicare and Medicaid Services used its demonstration authority under Section 402(a)(1)(A) of the Social Security Amendments of 1967 to build a workaround that operates entirely outside the normal Part D benefit structure.¹

The practical result: your individual Part D plan has nothing to do with a Bridge prescription. Prior authorization, claims, and pharmacy payment all flow through a central processor run by Humana.² Foundayo is one of three GLP-1 medications on the Bridge formulary, alongside Wegovy (in injection and tablet forms) and Zepbound (KwikPen only; single-dose vials and pens are not covered). All three carry the same $50 monthly copay.³

Who Qualifies for Foundayo Under Medicare

You must be at least 18 years old and enrolled in a Medicare Part D plan, either standalone or as part of a Medicare Advantage plan with drug coverage. On top of that, you have to fall into one of three clinical tiers based on your body mass index at the time therapy starts:⁴

BMI of 35 or higher, with no additional condition required.
BMI of 30 or higher, plus heart failure with preserved ejection fraction, uncontrolled hypertension despite two or more medications, or chronic kidney disease at stage 3a or above.
BMI of 27 or higher, plus prediabetes, a prior heart attack, a prior stroke, or symptomatic peripheral artery disease.

If you started GLP-1 therapy before July 1, 2026, your BMI at the time you first began treatment is what counts, even if you weigh less now.⁵

Conditions That Send You Back to Your Part D Plan

The Bridge is only for beneficiaries who have no other route to Medicare coverage for GLP-1s. If you have type 2 diabetes, moderate-to-severe obstructive sleep apnea, or noncirrhotic metabolic dysfunction-associated steatohepatitis (sometimes called MASH or fatty liver disease), your Part D plan is already required to cover a GLP-1 for that condition, and you cannot use the Bridge.³ That is true even if you also have obesity. You would go through your plan’s formulary and prior authorization process instead.² CMS has said it will watch for plans steering patients with covered conditions into the Bridge to avoid their Part D obligations.

What You Will Pay

The copay is $50 for each 30-day supply, and it does not move up or down. What surprises many people is how walled off this payment is from the rest of the Part D benefit:

The $50 does not apply to your Part D deductible and does not count toward true out-of-pocket costs. It will not show up on your Medicare Summary Notice.³
It does not count toward the $2,000 annual out-of-pocket cap, and the cap does not reduce it either.¹
Extra Help, the low-income subsidy that reduces Part D costs, cannot lower the $50.³
Pharmacies cannot apply manufacturer copay coupons or discount cards to Bridge claims.⁶

The commercial savings card that Lilly offers for Foundayo, which can bring the cost as low as $25 a month, is not available to anyone on Medicare, Medicaid, TRICARE, VA, or another government plan.⁷ Lilly’s Self-Pay Journey Program, with prices from $149 to $299 per month, requires patients to forgo any third-party reimbursement, and those payments cannot be applied toward Medicare deductibles or out-of-pocket limits.⁴ For lower-income patients, the PAN Foundation opened an Obesity Copay Assistance Fund in July 2025 that offers up to $1,000 a year toward obesity treatment costs for households at or below 300% of the federal poverty level, provided the insurance already covers the medication.⁸

How to Fill a Prescription Through the Bridge

Your prescriber submits a prior authorization directly to the central processor, attesting that you meet the BMI and health criteria and that Foundayo is being prescribed for weight management along with a reduced-calorie diet and increased physical activity. You do not need a Part D denial first. Once approved, the authorization covers refills and dose changes through December 31, 2027, without resubmission, unless you switch to a different covered GLP-1.⁶

You can use any pharmacy; they do not have to opt in. Fills are limited to a single 28- or 30-day supply at a time, so 60- and 90-day fills are not available.⁶ Your prescriber does not need to be enrolled in Medicare, but cannot be on the CMS Preclusion List.⁹

What Happens When the Bridge Ends

The program was written as a stopgap. CMS had planned to fold GLP-1 coverage into a longer-term framework called the BALANCE Model (Better Approaches to Lifestyle and Nutrition for Comprehensive Health), which would have built the drugs into Part D plans starting in January 2027, with copays capped at $50 for enhanced plans and $125 for basic plans.¹⁰

On April 21, 2026, CMS delayed the Part D portion of BALANCE indefinitely, citing the need for further evaluation and data collection.¹¹ The Bridge was extended through the end of 2027 to keep access in place while the agency decides what comes next. No new BALANCE timeline has been announced.

Congress has been working a parallel track. The Treat and Reduce Obesity Act, which would amend Part D to explicitly cover anti-obesity medications, was reintroduced in 2025 as H.R. 4231 in the House and S. 1973 in the Senate.¹² Both remain in committee. Even if enacted, the bill specifies that the Part D coverage change would take effect two years after passage.

About Foundayo

Foundayo (orforglipron) is a once-daily oral GLP-1 receptor agonist from Eli Lilly. The FDA approved it on April 1, 2026, for adults with obesity, or adults with overweight who have at least one weight-related health condition, to be used alongside a reduced-calorie diet and increased physical activity.¹³ Unlike Wegovy and Zepbound, it is a pill taken without food or water restrictions rather than an injection. Its wholesale list price is $649 per month, well below the roughly $1,000 to $1,350 list prices for the injectable GLP-1s, though what you pay through the Bridge is $50 either way.¹⁴

1
CMS.gov. Medicare GLP-1 Bridge
2
CMS.gov. Information for Part D Plans
3
Medicare.gov. Weight Loss Drugs
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Foundayo by Lilly. Savings and Coverage
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CoreLife MD. Medicare GLP-1 Bridge Eligibility
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CMS.gov. Information for Pharmacies
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Foundayo by Lilly. Coverage and Savings
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PAN Foundation. PAN Foundation Opens First Obesity Copay Fund
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Midwest Mind and Body Healthcare. Medicare GLP-1 Bridge
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KFF. What to Know About the BALANCE Model for GLP-1s in Medicare and Medicaid
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American Hospital Association. CMS Delays Part D Portion of BALANCE Model Expansion of GLP-1 Access
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BillTrack50. H.R. 4231 Treat and Reduce Obesity Act
13
FDA. FDA Approves First New Molecular Entity Under National Priority Voucher Program
14
Reuters. Pricing and Availability of Novo and Lilly’s Weight Loss Drugs