Medicare GLP-1 Bridge: $50/Month for Foundayo, Wegovy & Zepbound
What the Bridge actually covers
- Price:flat $50/month out-of-pocket copay for eligible Part D enrollees, for a drug on a participating plan's formulary at the Bridge tier.
- Covered drugs: Foundayo tablets, Wegovy (injection and oral tablet), Zepbound KwikPen only. NOT Zepbound vials, NOT Ozempic, NOT Mounjaro.
- Effective dates: July 1, 2026 through December 31, 2027.
- Eligibility: Part D enrollee, 18+, and BMI ≥35, or BMI ≥30 with CKD/HFpEF/uncontrolled hypertension, or BMI ≥27 with prediabetes or prior MI/stroke/symptomatic PAD.
- Cash-pay backup: LillyDirect ($149/mo for Foundayo's lowest dose) and NovoCare ($349/mo for Wegovy) remain available to Medicare beneficiaries regardless of Bridge formulary status - these are direct-to-consumer cash programs, not copay-assistance cards, so anti-kickback rules don't block them.
What to do right now
- Check your Part D plan's formularyfor Foundayo, Wegovy, or Zepbound listed at the Bridge $50 tier - your plan's member portal or Member Services can confirm.
- Confirm you meet the BMI/comorbidity criteria with your prescriber before assuming eligibility - the Bridge has specific documented thresholds, not a blanket weight-loss qualification.
- If your plan has not added a Bridge drug, file a Part D formulary exception request through your prescriber (standard decisions run 72 hours, expedited 24 hours).
- Keep the cash-pay paths on hand as backup- run the math on LillyDirect or NovoCare self-pay against your plan's standard copay in case the $50 tier is not yet available on your specific plan.
Frequently asked questions
Is this the "BALANCE Model" I heard about, or something different?
Something different, and the distinction matters. When Eli Lilly first announced $50/month Medicare pricing for Foundayo in mid-2026, early coverage (including our own earlier version of this page) used the shorthand "BALANCE Model." CMS's actual Part D BALANCE Model track was indefinitely postponed on April 21, 2026. What launched on schedule July 1, 2026 instead is a separate, standalone CMS demonstration called the Medicare GLP-1 Bridge, running through December 31, 2027. Same $50/month copay figure, same July 1 date - different program, different name, and importantly, different scope (it covers three drugs, not just Foundayo - see below).
Which drugs does the Medicare GLP-1 Bridge actually cover?
Foundayo (orforglipron) tablets, Wegovy (both injection and the oral tablet), and Zepbound KwikPen - the pre-filled auto-injector pen specifically. Zepbound single-dose vials are explicitly excluded from the Bridge. Ozempic and Mounjaro are not covered under the Bridge at all, because both carry diabetes indications rather than the weight-management indication the Bridge targets.
What is the exact eligibility criteria?
You must be a Medicare Part D enrollee, age 18+, and meet one of: BMI ≥35, or BMI ≥30 with a qualifying comorbidity (stage 3a+ chronic kidney disease, heart failure with preserved ejection fraction, or uncontrolled hypertension), or BMI ≥27 with prediabetes, a prior heart attack or stroke, or symptomatic peripheral artery disease. Patients whose primary indication is type 2 diabetes, obstructive sleep apnea, or MASH (metabolic dysfunction-associated steatohepatitis) are excluded from this specific pathway - though they may have other Part D coverage paths for those indications.
How does this differ from Wegovy's existing Medicare coverage?
Wegovy gained limited Medicare Part D coverage in March 2024 after the FDA expanded its label to include cardiovascular risk reduction in ASCVD patients (based on the SELECT trial) - that pathway required documented atherosclerotic cardiovascular disease (prior MI, stroke, PAD, or revascularization) and did not offer a flat $50 copay. The Medicare GLP-1 Bridge is broader: it reaches patients with obesity-driven risk factors (not just confirmed ASCVD) at a guaranteed flat copay, and it also brings Zepbound and Foundayo into Medicare coverage for the first time.
Is my Part D plan required to participate?
The Bridge is a CMS demonstration that participating Part D plans opt into; check your plan's formulary directly for Foundayo, Wegovy, or Zepbound KwikPen listed at the Bridge tier. If your plan has not added one of the three drugs, you have two fallback options: file a Part D formulary exception request through your prescriber, or pay cash - LillyDirect for Foundayo (149/mo lowest dose) or Zepbound ($299/mo lowest dose), or NovoCare for Wegovy ($349/mo). Medicare enrollment does not block these manufacturer self-pay programs - they are direct-to-consumer cash programs, not copay-assistance cards, so the anti-kickback statute that blocks Medicare patients from manufacturer savings cards does not apply.
Does the $50/month Bridge copay work with Medicare Advantage?
Medicare Advantage plans must cover at least what traditional Medicare + Part D covers, but they administer their own formularies and prior-authorization rules independently. Some MA plans - particularly those treating obesity management as a quality measure - may add Bridge-eligible drugs faster than standalone Part D plans. Check your specific MA plan's member portal to confirm.
Is the Bridge the same as a manufacturer savings card?
No. Manufacturer savings cards (the Foundayo Savings Card, Wegovy Savings Card, Zepbound Savings Card) are blocked by federal anti-kickback rules for any patient with government insurance - Medicare, Medicaid, Tricare, or VA. The Medicare GLP-1 Bridge is a CMS-run demonstration operating through the Part D benefit structure itself, which is why it can legally reach Medicare beneficiaries where a manufacturer card cannot.
What if I have Medicare + Extra Help (Low-Income Subsidy)?
Extra Help / LIS typically reduces Part D copays to $0-$11/month for covered drugs. If your plan has added a Bridge-eligible drug to its formulary and you qualify for full LIS, your out-of-pocket could land below the $50/month Bridge floor. LIS does not help if the drug is not yet on your plan's formulary at all - the underlying formulary-inclusion gap matters more than the subsidy in that case.
How long does the Medicare GLP-1 Bridge run?
Through December 31, 2027. It was originally structured as a shorter demonstration but CMS extended it to a full 18 months after postponing the Part D track of the BALANCE Model that was originally meant to follow it starting January 2027. A separate BALANCE Model track for Medicaid (not Medicare) is proceeding on its own rolling state-adoption timeline from May 2026 through January 2027, running through December 2031 - a different program covering a different beneficiary population, and not what this page is about.
My pharmacy says I am not covered even though I am eligible - what is going on?
This is a known, common problem in the Bridge's first weeks, not necessarily a real denial. The Bridge runs entirely outside your normal Part D claims pathway on its own separate processor - if the pharmacy submits your claim the standard way (through your regular Part D plan), it gets auto-rejected, because the Bridge is billed through its own BIN 028918 / PCN MEDDGLP1BR instead. Ask the pharmacist directly whether the claim was submitted under BIN 028918 / PCN MEDDGLP1BR - that single question resolves most of what looks like a coverage denial but is actually a misdirected claim. CMS and NCPA (the pharmacy trade group) have both published guidance and a reject-code cheat sheet for pharmacies still adjusting to the new billing pathway.
Related guides
Track Foundayo (orforglipron) pricing and availability
Eli Lilly's daily oral pill Foundayo (orforglipron) was FDA-approved April 1, 2026 and starts at $149/mo via LillyDirect. We'll email you when pricing tiers change, insurance coverage expands, or new head-to-head data lands vs. Wegovy and Zepbound.