Best FDA-Approved GLP-1 on Navitus Formulary (2026): What's Actually Covered

What we actually verified for this page

We pulled and cross-checked three public 2026 Navitus formularies:

• State of Wisconsin Group Health Insurance Program formulary (wisconsin.edu/ohrwd/benefits/download/formulary.pdf)
• SISC (Self-Insured Schools of California) Navitus prescription formulary (bsspjpa.org/navitus-prescription-formulary)
• University of California MedicareRx (PDP) formulary, HPMS Approved File ID 00026151 v07, updated 09/26/2025

We confirmed FDA-approved indications against the current drug labels for Wegovy, Zepbound, Foundayo, Saxenda, Ozempic, Mounjaro, Rybelsus, and Trulicity. We pulled current self-pay pricing from NovoCare, Sesame, LillyDirect, and Ro.

What we could not verify: every Navitus-administered employer plan in the country (Navitus serves hundreds), every state-specific provider availability, and your individual benefits. We also found at least one third-party coverage database listing some Navitus plans as covering Wegovy with no prior authorization, no step therapy, and no quantity limit — which directly contradicts the public sponsor formularies we reviewed. The honest takeaway: your specific plan can differ significantly from any example, so treat this page as a coverage interpretation guide, not a guarantee of benefits.

What is the best FDA-approved GLP-1 on Navitus formulary in 2026?

That's the short version. The rest of the page handles every angle of the longer answer — what Navitus actually is, what the codes in your portal mean, what's covered for diabetes vs. weight loss, the prior-authorization playbook, the Medicare GLP-1 Bridge launching July 1, 2026, what to do if your plan excludes the drug you want, and the real cash-pay prices if you go that route.

The Navitus GLP-1 Coverage Reality Matrix (2026)

Sources: Wisconsin GHIP 2026 Formulary (wisconsin.edu/ohrwd/benefits); SISC Navitus prescription formulary (bsspjpa.org); UC MedicareRx 2026 PDP Approved File ID 00026151 v07 (medicaresupplement.universityofcalifornia.edu/document/233); current FDA drug labels; CMS Medicare GLP-1 Bridge FAQ (cms.gov/medicare/coverage/prescription-drug-coverage/medicare-glp-1-bridge).

What this tells you in one sentence: If your search is about a weight-loss-only prescription, the FDA-approved obesity drugs are the right clinical answer but a long shot on standard coverage — plan on prior authorization, an alternative-indication pathway, or self-pay. If your search is about type 2 diabetes, the diabetes-labeled GLP-1s are listed with paperwork requirements but are realistic coverage paths.

What Navitus actually is (and why your plan matters more than the brand)

Here's the thing most pages get wrong. They write as if “Navitus” is one formulary you can look up. It isn't. Navitus runs different formularies for different clients. The University of California uses one. The State of Wisconsin uses another. SISC (the school plan in California) uses a third. OhioHealthy has its own. Same PBM, different drug lists. That's why a coworker on Navitus might tell you Wegovy is covered while your portal says it's excluded — you're on different plans.

Five short definitions you'll need, because the codes in your portal are not going to explain themselves:

• Tier:A number (Tier 1, 2, 3, 4) that sets your share of the cost. Tier 1 is usually generics and cheapest. Tier 4 is usually specialty and most expensive.
• PA (prior authorization):Your prescriber has to send paperwork showing you meet the plan's criteria before the plan will pay.
• QL (quantity limit):The plan only covers a set amount per fill — like one pen every 28 days.
• RDX (restricted to diagnosis):The plan only pays if the prescription matches a specific covered diagnosis on the claim.
• EXC (excluded):The drug is on the list but not paid for under normal benefits.

What “100%/EXC” really means on a Navitus formulary

This is the single biggest source of confusion in Navitus GLP-1 land, and it's not your fault. The word “Covered” appears right next to the EXC code in many member portals. People reasonably assume “Covered” means their plan pays. Then they get the pharmacy quote.

One Navitus member on Reddit summed it up perfectly: “Covered – Level 100%/EXC” — followed by a pharmacy price showing in the four figures. That's the exact pattern. The drug is technically “on the list,” but the plan has excluded it from paid benefits.

Why that happens

Plan sponsors decide whether to cover anti-obesity medications. Many still exclude them because of cost — Wegovy's list price runs $1,300–$1,600 per month, Zepbound runs $1,000–$1,300 per month, and these drugs have exploded in demand. GoodRx reported that over 12 million people lost some form of commercial insurance coverage for Wegovy in 2026. When plan sponsors decide not to cover weight-loss drugs, Navitus still lists them in the formulary document for transparency — but flags them as excluded.

The Navitus code translator (use this to read your own portal)

What to do if you see EXC or 100%/EXC

1. Screenshot it. Date-stamp the screen. You'll want this if you file an exception.
2. Check the category. If the drug is in the “anti-obesity agents” section, the exclusion is policy-driven. If it's in the “diabetes” section, it's a different conversation entirely.
3. Call Navitus at the number on the back of your member ID card. Ask three specific questions: Is this drug fully excluded, or only excluded for certain uses? Is an exception process available? Which FDA-approved alternatives are preferred?
4. Loop in your prescriber. If you have a documented condition that triggers a different FDA-approved use — like obstructive sleep apnea, established cardiovascular disease, or MASH — the prescription framing changes, and so might coverage.
5. Have a backup ready. If your plan won't pay, you have legitimate self-pay paths at transparent pricing (covered below).

Is Wegovy covered by Navitus?

Wegovy has more pathways than most GLP-1s, and that matters here. The FDA has approved Wegovy for:

• Chronic weight management in adults with obesity (BMI ≥30) or overweight (BMI ≥27 with at least one weight-related condition)
• Chronic weight management in pediatric patients 12 and older with obesity
• Reducing the risk of major adverse cardiovascular events (heart attack, stroke, cardiovascular death) in adults with established cardiovascular disease and either obesity or overweight
• Treatment of adults with noncirrhotic MASH (metabolic dysfunction-associated steatohepatitis) with moderate-to-advanced fibrosis under accelerated approval — Wegovy injection received this indication on August 15, 2025. Wegovy tablets are not established for MASH.

That last point matters because some Navitus plans that exclude weight-loss-only use will cover Wegovy injection when the prescription is documented for a different FDA-approved indication. If you have a CV disease history or MASH, talk to your prescriber about the framing.

Typical Wegovy PA criteria on Navitus commercial plans

• BMI ≥30, or BMI ≥27 with at least one weight-related condition (type 2 diabetes, hypertension, high cholesterol, OSA, established CVD)
• Documentation of a structured lifestyle program lasting 3 to 6 months in the past 2 years
• Prescriber attestation that Wegovy is part of a comprehensive weight-management plan
• Some plans require step therapy — a documented trial of cheaper drugs (phentermine, Contrave, Saxenda) before Wegovy approval
• Several 2026 Navitus-administered plans tightened criteria to require pre-treatment BMI ≥40 for new starts (UC PPO, Valley Health Plan 2026)

Wegovy self-pay reality if your plan excludes it

Verified numbers as of May 2026:

• NovoCare cash price: $199/month for the first two fills of 0.25 mg or 0.5 mg through June 30, 2026, then $349/month for standard doses and $399/month for Wegovy HD. Source: novocare.com.
• Sesame Wegovy pen: Starts at $199/month for the first two fills, then $349/month. Source: sesamecare.com.
• Sesame Wegovy pill: $149/month for 1.5 mg and 4 mg starter doses; $299/month for 9 mg or 25 mg maintenance doses. Source: sesamecare.com.
• Sesame + Costco Pharmacy: Costco members can access Wegovy or Ozempic injections for $349/month self-pay at Costco Pharmacy through Sesame. Source: sesamecare.com.
• Ro: Medication prices aligned with NovoCare, LillyDirect, and TrumpRx, with a separate Ro Body membership fee — $39 for the first month, then as low as $74/month with the annual plan paid upfront.

Is Zepbound covered by Navitus?

The OSA pathway is the most underused move in this category, and it's worth understanding because it's the difference between a denial and a paid prescription for thousands of people:

• The FDA approved Zepbound for moderate-to-severe OSA in adults with obesity in December 2024.
• Typical insurance criteria require an apnea-hypopnea index (AHI) of 15 or higher documented by a sleep study (polysomnography or home sleep test), a BMI ≥30, and either intolerance to or inadequate response to CPAP.
• When the prescription is tied to ICD-10 G47.33 (obstructive sleep apnea), the claim framing changes from “weight loss” to “sleep medicine.”
• Some Navitus plans that exclude weight-loss-only use will pay for Zepbound under the OSA indication. Not all. But it's worth asking your sleep doctor and prescriber if the criteria fit.

The wider Zepbound coverage trend

For context: CVS Caremark's own published material confirms Zepbound was no longer included in its Standard Control, Advanced Control, and Value formularies effective July 1, 2025, with Wegovy continued as a preferred similar medication. That move pushed millions off Zepbound coverage on CVS Caremark plans. Navitus has not made an equivalent industry-wide announcement, but the broader trend toward tighter weight-loss-drug formularies is across the industry.

Zepbound self-pay reality if your Navitus plan excludes it

• LillyDirect / Zepbound self-pay: Starts at $299/month for 2.5 mg and $399/month for 5 mg. Self-pay journey program: $449/month for 7.5 mg, 10 mg, 12.5 mg, and 15 mg when program terms are met. Source: lilly.com/lillydirect.
• Ro: Carries Zepbound at LillyDirect-aligned medication pricing, with Ro Body membership $39 for the first month, then as low as $74/month with the annual plan paid upfront.
• Sesame Zepbound KwikPen: $299/month for 2.5 mg; $398/month for 5 mg; $499/month for 7.5 mg; $698/month for 10, 12.5, or 15 mg. Source: sesamecare.com.

What about Foundayo on Navitus?

Until Foundayo, every FDA-approved weight-loss GLP-1 was an injection (Wegovy, Zepbound, Saxenda). Foundayo is a once-daily oral tablet — no injection, no temperature-controlled storage, no needle sourcing.

A few things to know before you ask your doctor:

• Boxed warning for thyroid C-cell tumors. Foundayo's FDA label carries a boxed warning. It should not be used in patients with a personal or family history of medullary thyroid cancer or Multiple Endocrine Neoplasia syndrome type 2 (MEN2).
• Do not combine GLP-1s. Foundayo's label states it should not be used with another GLP-1 receptor agonist. If you're on Wegovy, Zepbound, Ozempic, or any GLP-1, you can't simply add Foundayo on top.
• Side effects mirror the injectable GLP-1s. Common gastrointestinal effects include nausea, vomiting, diarrhea, constipation, decreased appetite, and abdominal pain.

Foundayo coverage and access in 2026

• Most Navitus commercial plans: Listed in the anti-obesity section but typically EXC or 100%/EXC right now.
• Medicare GLP-1 Bridge (starting July 1, 2026): All formulations of Foundayo are eligible at $50/month copay for qualifying beneficiaries who meet the clinical criteria. Source: CMS Medicare GLP-1 Bridge FAQ.
• Ro cash-pay: Carries Foundayo, with medication billed separately from Ro Body membership.
• Sesame cash-pay: Foundayo from $149/month at the starter dose, up to $349/month at maintenance doses. Source: sesamecare.com.

Ozempic, Mounjaro, and the diabetes path on Navitus

Ozempic and Wegovy are the same molecule — semaglutide — but they're not the same drug. They're approved for different indications, at different doses, and your insurance will treat them differently. If your prescription is written as “Ozempic for weight loss” without a type 2 diabetes diagnosis on the claim, it's an off-label prescription, and a plan that requires the T2D diagnosis will deny it.

The same is true for Mounjaro and Zepbound. Both are tirzepatide. Mounjaro is the diabetes-labeled brand. Zepbound is the obesity-labeled brand. Same molecule. Different FDA approvals. Different formulary slots. Different coverage outcomes.

Diabetes GLP-1s on Navitus MedicareRx 2026 PDP

Source: Navitus MedicareRx 2026 PDP UC formulary, HPMS Approved File ID 00026151 v07, updated 09/26/2025.

What this means for you

• If you have type 2 diabetes: The public Navitus examples list at least one diabetes GLP-1 with restrictions on every formulary we reviewed. Get the paperwork right — your prescriber needs to document your diagnosis (ICD-10 code E11.x), your A1c, any prior diabetes treatments tried, and submit the prior authorization. You have a realistic path.
• If you don't have type 2 diabetes: These drugs are the wrong route. Wegovy is the FDA-approved semaglutide for your situation. Zepbound is the FDA-approved tirzepatide. Foundayo is the FDA-approved oral option.

For a deeper look at Mounjaro and the diabetes pathway specifically, see our guide on best tirzepatide for type 2 diabetes.

So which FDA-approved GLP-1 on Navitus formulary is actually best (if your plan covers it)?

The head-to-head data

In the SURMOUNT-5 trial (Aronne et al., NEJM 2025), adults with obesity and without diabetes who took tirzepatide lost more weight than those who took semaglutide over 72 weeks. Both worked. Tirzepatide worked more on average — that is a trial result, not a guarantee for any individual.

Three real reasons to pick Wegovy over Zepbound:

1. You have established cardiovascular disease. Wegovy carries an FDA-approved indication for reducing major adverse cardiovascular events in adults with CVD and obesity or overweight. Zepbound does not.
2. You're under 18. Wegovy is FDA-approved for adolescents 12 and older with obesity. Zepbound is not established for pediatric patients.
3. You have MASH with moderate-to-advanced fibrosis. Wegovy injection received this FDA indication in August 2025 under accelerated approval.

Three real reasons to pick Foundayo:

1. You won't take an injection. Some people simply won't. Foundayo eliminates that barrier.
2. You travel constantly. No refrigeration. No needles. Pop the pill.
3. You want the newest option with reasonable cash-pay pricing at $149/month starter.

And one reason to pick Saxenda: your plan covers Saxenda and not the others. That's actually a legitimate scenario for some employer plans.

How much could FDA-approved GLP-1s cost if Navitus does not pay?

Prices verified May 13, 2026. Pricing changes; reconfirm before ordering.

How to check YOUR exact Navitus plan in 5 minutes

1. Find your Navitus member ID. It's on the back of your insurance card. Look for the Navitus logo.
2. Go to memberportal.navitus.com. Log in with your member ID. First-time users will need to register; have your card and a personal email handy.
3. Click “Find a Drug” (sometimes “Medication Lookup”). This is the search tool that pulls your specific plan's current rules.
4. Type the exact brand name. Try the full FDA brand: “Wegovy,” “Zepbound,” “Foundayo,” “Ozempic.” If you only type “semaglutide,” you may get partial results.
5. Read the result carefully. Look for: tier number, copay estimate, PA / QL / ST / RDX flags, and the EXC code if present. If you see “100%/EXC” or “EXC,” that's not coverage in the normal sense — call Navitus to confirm.

If your portal is down or you're between insurance plans, call the member services number on the back of your card. The number for the Navitus MedicareRx PDP is 1-866-270-3877 as of the 2026 formulary document.

The Navitus prior authorization playbook (so you don't get denied)

Required for any GLP-1 PA

• Patient demographics and insurance plan information
• The exact drug, dose, and quantity requested (e.g., “Wegovy 2.4 mg, 1 pen, 28-day supply”)
• ICD-10 diagnosis code(s)
• Current weight and height with calculated BMI (and date of measurement)
• Statement of medical necessity

Required for weight-management drugs (Wegovy, Zepbound, Foundayo, Saxenda)

• BMI ≥30 documented, or BMI ≥27 with at least one weight-related comorbidity (type 2 diabetes, hypertension, high cholesterol, OSA, established CVD)
• Some plans now require BMI ≥40 for new starts (UC PPO 2026, Valley Health Plan 2026)
• Documentation of lifestyle modification: 3 to 6 months of structured diet/exercise/behavioral effort within the past 2 years
• For some plans: prior medication trials and outcomes (step therapy through phentermine, Contrave, or Saxenda)
• Reauthorization usually requires documented weight loss of ≥5% from baseline

Required for diabetes GLP-1s (Ozempic, Mounjaro, Rybelsus, Trulicity)

• Confirmed type 2 diabetes diagnosis (ICD-10 E11.x)
• A1c value with date
• Prior diabetes medications tried (many plans require step therapy through metformin)

Common ICD-10 codes you'll see on GLP-1 PAs

How to submit

• Mail: Navitus Health Solutions LLC, Attn: Prior Authorizations, 1025 West Navitus Dr., Appleton, WI 54913
• Phone: For urgent requests, prescribers can call to initiate
• Fax: Plan-specific; on the Navitus PA form
• Electronic PA: Available through some plan integrations

If denied: the appeal ladder

For commercial plans: Most internal appeals must be filed within 180 days from the denial letter (healthcare.gov). Your appeal should include a stronger Letter of Medical Necessity from your prescriber, any new clinical evidence, and an explicit response to the denial reason. If the internal appeal is denied, you can request external review through your state insurance department.

For Medicare Part D plans: The CMS appeals process moves through plan redetermination → Independent Review Entity → Administrative Law Judge → Medicare Appeals Council → Federal Court. Read your denial letter carefully — the deadline and process are on the letter.

If your Navitus plan won't cover the GLP-1 you want

Path 1: Request a formulary exception

Some Navitus plans allow exceptions even when the drug is excluded. Your prescriber files a request with a Letter of Medical Necessity arguing that the excluded drug is medically necessary for your specific situation and that the covered alternatives are inadequate. Success rates vary by plan and condition. This works best when you have a documented contraindication or failure on covered alternatives.

Path 2: Use the alternative-indication pathway (when it genuinely fits)

If you have a real, documented condition that triggers a different FDA-approved use of the same drug, the prescription framing changes:

• Wegovy injection + established CV disease: Approved for major adverse CV event risk reduction. Some plans that exclude weight-loss-only use will cover this.
• Wegovy injection + MASH (moderate-to-advanced fibrosis): Approved August 15, 2025 under accelerated approval. Wegovy tablets are not approved for MASH.
• Zepbound + moderate-to-severe OSA: Approved December 2024. Some plans will cover Zepbound under G47.33 when they won't cover it for E66.01.

Path 3: Cash-pay through Ro

Ro carries FDA-approved Zepbound, Foundayo, and Wegovy at medication prices Ro states are aligned with LillyDirect / NovoCare / TrumpRx, runs your insurance eligibility check for you, and can help with prior authorization if your plan does cover it. Ro Body membership: $39 for the first month, then as low as $74/month with the annual plan paid upfront ($149/month if you pay monthly). Medication is billed separately at the cash-pay rate.

Path 4: Manufacturer-direct cash pay or Sesame self-pay

• NovoCare Wegovy: $199/month for first two fills (0.25 mg / 0.5 mg) through June 30, 2026, then $349/month standard doses, $399/month Wegovy HD. Wegovy pill from $149/month.
• LillyDirect Zepbound: $299/month for 2.5 mg; $399/month for 5 mg; $449/month for 7.5–15 mg via the self-pay journey program.
• Sesame Care: Wegovy pill from $149/month; Wegovy pen from $199/month first two fills then $349/month; Zepbound KwikPen from $299/month; Foundayo from $149/month at starter dose.

Navitus Medicare members and the Medicare GLP-1 Bridge (July 1, 2026)

Who qualifies for the Bridge

Per the CMS Medicare GLP-1 Bridge FAQ:

• You must be an eligible Medicare Part D beneficiary (standalone PDP or MA-PD).
• You must meet clinical criteria at the time of GLP-1 therapy initiation — typically BMI ≥30, or BMI ≥27 with a qualifying weight-related condition.
• Your prescriber submits a prior authorization request to the Bridge program.

What's covered and what's not

• Covered through the Bridge: All formulations of Foundayo, all formulations of Wegovy (injection and tablets), and the KwikPen formulation of Zepbound.
• Not covered through the Bridge: Zepbound single-dose vials and single-dose pens.
• Not covered through the Bridge: GLP-1 prescriptions for indications other than weight reduction. Wegovy for CV disease, Wegovy for MASH, and Zepbound for OSA go through your standard Part D plan, not the Bridge.

How the Bridge interacts with your Navitus MedicareRx formulary

It doesn't. The Bridge operates independently of your Part D plan's formulary. Even if Wegovy, Zepbound, or Foundayo isn't on your Navitus MedicareRx drug list, you can still access them through the Bridge if you meet eligibility criteria.

One important rule: manufacturer coupons and copay assistance programs cannot be applied to Bridge claims. The $50/month is the price.

What comes after the Bridge

CMS extended the Medicare GLP-1 Bridge through December 31, 2027 to collect additional utilization data ahead of potential BALANCE Model implementation in Part D. CMS has described a $245 net price per 30-day supply framework covering Foundayo, Mounjaro, Ozempic, Rybelsus, Wegovy (all formulations), and Zepbound (KwikPen). The full BALANCE Model implementation remains potential rather than guaranteed; check cms.gov/medicare/coverage/prescription-drug-coverage/medicare-glp-1-bridge for the latest status.

If you're a Navitus MedicareRx member and you want a weight-loss GLP-1, your two real paths are: (1) the Bridge, if you qualify (starts July 1, 2026), or (2) cash pay, if you don't.

Risks, side effects, and what to ask your prescriber

Contraindications to discuss with your prescriber

The FDA-approved GLP-1s covered on this page (Wegovy, Zepbound, Saxenda, Foundayo) carry a boxed warning for thyroid C-cell tumors. You should not start any of them if you have:

• A personal history of medullary thyroid carcinoma
• A family history of medullary thyroid carcinoma
• Multiple Endocrine Neoplasia syndrome type 2 (MEN2)

Other serious warnings to review with your prescriber:

• Pancreatitis — discontinue if suspected.
• Gallbladder disease — risk of acute cholecystitis with rapid weight loss.
• Acute kidney injury — severe dehydration from GI side effects can damage kidneys.
• Severe gastrointestinal disease, including gastroparesis — not recommended or requires caution per many labels.
• Hypoglycemia risk — significantly higher when combined with insulin or sulfonylureas.
• Pregnancy — weight-loss GLP-1s are not for use in pregnancy. Use specific drug label guidance and prescriber direction.

Do not combine GLP-1s

Foundayo's label explicitly states it should not be used concomitantly with another GLP-1 receptor agonist. The same principle applies across the class — combining two GLP-1s is not established as safe and is not approved by the FDA for any combination.

Common side effects across FDA-approved weight-loss GLP-1s:

• Nausea (very common; often improves with time)
• Vomiting
• Diarrhea
• Constipation
• Abdominal pain
• Decreased appetite
• Headache
• Fatigue

What to ask your prescriber

• Do I have any personal or family history that puts me at higher risk?
• What's my BMI and which FDA-approved indication fits my situation?
• What's the right starting dose, and how do you plan dose escalation?
• What do I do if I have severe nausea or vomiting?
• How will we monitor — labs, weight, side effects, anything else?
• What's the plan if I don't tolerate this drug?
• What's the plan if my insurance denies coverage?

Honest tradeoffs we'd tell a friend

1. Even covered, GLP-1s aren't free. Tier 2 with PA still means out-of-pocket costs varying by your specific plan's copay structure. If your plan covers Wegovy and your copay is $50/month, that's a win. If it covers Wegovy and your copay is $300/month, that's still a real expense.
2. The “best drug” question is partly about what your plan pays for. If your plan covers Saxenda and not Zepbound, Saxenda might be your best practical option even though it's not the strongest weight-loss molecule. The clinically best drug you can't get is worse than the clinically second-best drug you can.
3. Compounded GLP-1 products are a different category and outside this page's scope. They are not FDA-approved drugs. They are not the same regulatory class as the medications above. If you're considering compounded options, that's a different conversation — read about it on a page that handles compounded products specifically.

How we built this page (methodology)

The RX Index is a pricing intelligence and comparison resource for GLP-1 telehealth providers. We do not provide medical advice. We do not prescribe. We do not run a pharmacy. We help people interpret what their coverage actually means and route them to legitimate FDA-approved options.

Public Navitus documents reviewed

• State of Wisconsin Group Health Insurance Program 2026 Formulary (wisconsin.edu/ohrwd/benefits/download/formulary.pdf)
• SISC Navitus Prescription Formulary 2026 (bsspjpa.org/navitus-prescription-formulary)
• University of California MedicareRx (PDP) 2026 Formulary (HPMS Approved File ID 00026151 v07, updated 09/26/2025) (medicaresupplement.universityofcalifornia.edu/document/233)
• Navitus Health Solutions Benefit Glossary (navitus.com/who-we-serve/members/benefit-glossary/)
• Navitus Prior Authorization process page (navitus.com/resource/prior-authorization/)

FDA sources reviewed

• Wegovy prescribing information (current label) and FDA MASH approval announcement (August 15, 2025)
• Zepbound prescribing information (current label) and FDA OSA approval (December 2024)
• Foundayo prescribing information (current label)
• Saxenda prescribing information
• Ozempic, Mounjaro, Rybelsus, Trulicity prescribing information

Clinical evidence cited

• Aronne et al., “Tirzepatide as Compared with Semaglutide for the Treatment of Obesity” — SURMOUNT-5 head-to-head trial, New England Journal of Medicine 2025

Commercial pricing sources

• Ro pricing page and GLP-1 Insurance Coverage Checker (ro.co/weight-loss/pricing, ro.co/weight-loss/glp1-insurance-checker)
• Sesame Care GLP-1 medication pricing (sesamecare.com)
• NovoCare Wegovy pricing (novocare.com)
• LillyDirect Zepbound pricing (lilly.com/lillydirect)

Regulatory and policy sources

• CMS Medicare GLP-1 Bridge FAQ (cms.gov/medicare/coverage/prescription-drug-coverage/medicare-glp-1-bridge)
• CMS BALANCE Model page (cms.gov/priorities/innovation/innovation-models/balance)
• Valley Health Plan 2026 weight-loss coverage update (valleyhealthplan.org)
• CVS Caremark GLP-1 formulary page for industry context (business.caremark.com)
• HealthCare.gov internal appeals process

Refresh cadence: Monthly through Q3 2026 (the Medicare Bridge launches July 1 and program details continue to evolve). Quarterly after that.

Frequently asked questions