in 4 days Aetna (CVS Health) — Zepbound back as additional preferred on templates See the changelog
WalletNoise

Optum Rx (UnitedHealthcare)

PBM standard commercial template (Premium Standard Formulary) · updated September 2, 2026

Coverage right now

Kept both Wegovy and Zepbound covered throughout 2025-2026 — no CVS-style exclusion — with PA + quantity limits throughout, though Zepbound is covered as the auto-injector only and the vials are excluded outright. Tier placement is a plan-level answer rather than a property of the formulary: booklets carrying the same 'Premium Standard Formulary' name and the same Jan 1 2026 effective date print these drugs at Tier 2 in one case and Tier 3 in another. Weight-loss coverage is an opt-in employer benefit. Foundayo joined the weight-loss PA policy on 9/1/2026 but has no published formulary tier and may be excluded at launch on some plans.

Drug status

DrugStatusDetailConfidence
Zepbound® (tirzepatide)Covered
from Jan 1, 2026
Tier 2, PA + QL — but only as the auto-injector: the booklet prints ZEPBOUND SUBCUTANEOUS SOLUTION AUTO-INJECTOR at Tier 2 and the plain ZEPBOUND SUBCUTANEOUS SOLUTION — the vials — as E, excluded. Device-level steering, the same shape as the Express Scripts KwikPen/vial exclusion. OSA pathway added July 2025 (policy P 1475-1: sleep study + CPAP requirements). sourcemedium
Wegovy® (semaglutide injection)Covered
from Jan 1, 2026
Tier 2, PA + QL. sourcemedium
Wegovy® tablets (oral semaglutide)Covered
from Jul 1, 2026
Covered under the weight-loss PA policy (P 1114-22 covers Wegovy injection and tablet); tier placement not shown in the Jan 2026 booklet. The policy footnotes Wegovy tablet as a product that 'may be in Exclude at Launch', so some plans may not cover it yet. sourcemedium
Foundayo™ (orforglipron)Unknown Absent from the Jan 2026 formulary booklet and the 7/1/2026 UHC weight-loss PA drug list — suggests non-formulary / new-to-market review as of Aug 2026. Verify with your plan. sourcelow
Foundayo™ (orforglipron)Varies
from Sep 1, 2026
Named in the weight-loss PA policy (P 1114-22) from 9/1/2026: initial authorization 6 months, reauthorization 12 months. The policy footnotes Foundayo and Wegovy tablet as products that 'may be in Exclude at Launch', so whether a given plan covers it at all is a plan-level answer. Still absent from the 2026 Premium Standard Formulary booklet, so no tier is published. sourcehigh
Saxenda® (liraglutide)Covered
from Jan 1, 2026
Tier 2, PA + QL. sourcemedium

What these rules come to in dollars — every dose, priced under this coverage:

What preferred, covered and exception only mean
Preferred
On the formulary at the plan's best tier for this class. Usually still needs prior authorization — preferred is not the same as automatic.
Covered
On the formulary, but not the plan's first choice for this class. Often a higher copay tier than a preferred drug.
Non preferred
On the formulary at a disadvantaged tier, or reachable only after trying a preferred drug first.
Exception only
Not routinely covered. Obtainable only through a formulary-exception request that meets the plan's published criteria.
Excluded
Not on the formulary at all. A benefit exclusion is a different fight from a PA denial and is appealed differently.
Varies
The payer's own documents differ by plan or line of business, so a single answer here would be wrong.
Unknown
Not yet verified against a primary document. Recorded as absent rather than guessed.
N/A
Not applicable to this payer.

Prior authorization criteria

high
PA required
Yes (PA + QL flags on formulary). Your benefit plan decides whether weight-loss medications are covered at all.
Initial BMI
BMI >= 30 (pediatric: > 95th percentile), OR BMI >= 27 with a documented weight-related comorbidity.
Comorbidities
Dyslipidemia, hypertension, type 2 diabetes, sleep apnea.
Lifestyle requirement
Used as an adjunct to lifestyle modification (dietary/caloric restriction, exercise, behavioral support, community program). Continuation required at reauth. No minimum duration stated — the loosest lifestyle requirement among the big three.
Initial authorization
Wegovy (inj/tablet)/Wegovy HD 5 · Zepbound/Foundayo/Xenical 6 · Saxenda/Contrave/Qsymia 4
Reauthorization
>= 5% of baseline weight for Wegovy/Zepbound (Saxenda >= 4%, Qsymia >= 3%). Reauthorization lasts 12 months.
Step therapy
None documented — no trial-and-failure of other anti-obesity medications required.
Quantity limits
QL flag applies; specific per-days quantities not published in retrieved documents.

Primary criteria document: uhcprovider.com

Exceptions and appeals

Appeal deadline
180 days
Deadline detail
180 days internal appeal (commercial, per denial letter / ERISA standard).
Exception route
Prescriber ePA via professionals.optumrx.com. Verbal PA / urgent line 1-800-711-4555 (5am-10pm PT M-F). Fax retired except MA/RI/SC/TX.
Turnaround
Not published by Optum Rx. Secondary reporting: electronic decisions from seconds up to 72 hours; 1-2 weeks for manual submissions.
Where
Per your denial letter (plan-specific).

Source: business.optum.com

Dated changes

  • Jul 1, 2025 UHC added Zepbound OSA pathway (policy P 1475-1) source
  • Jan 1, 2026 2026 Premium formulary exclusions (12 drugs) included no GLP-1 changes source
  • Jul 1, 2026 Weight-loss PA policy updated (P 1114-21): adds Wegovy tablet, MASH pathway source
  • Sep 1, 2026 Weight-loss PA policy P 1114-22 adds Foundayo (orforglipron) to the covered drug list at 6 months initial authorization, footnoted as possibly excluded at launch on some plans source
North Dakota EHB variant requires BMI >= 40 and limits coverage to Wegovy/Zepbound. Some plans pair coverage with mandatory engagement programs (Optum Rx Weight Engage). On the formulary citation: the booklet these rows cited until 2026-09-02 was a copy hosted by an employer (gateshealth.com) and it now 404s to curl and 403s to WebFetch, so it can no longer be read by anyone. The replacement is Optum's own copy on contenthub-aem.optumrx.com, same document name and same Jan 1 2026 effective date. It does not agree with the old one on tier — it prints Zepbound auto-injector, Wegovy and Saxenda at Tier 2 where the old copy showed Tier 3 — which is why every tier row here is now MEDIUM: both are client booklets of a formulary whose tiering the client's benefit design sets, and no Optum-published master template has been located that would settle which number is the default. The '++' flag against each of these rows in the booklet says the same thing in Optum's own notation: coverage is determined by the prescription benefit plan. Foundayo is absent from this booklet too, which is what the Foundayo row's 'no published tier' rests on.
These are each payer's standard template. Employer plans customize them, so the same PBM can cover a drug for one employer and exclude it for another — a status here is a starting point, not your plan. A benefit exclusion is also a different fight from a PA denial. Always request your own plan's criteria in writing; you are entitled to them.