UnitedHealthcare Wegovy Coverage: Optum Rx PA Criteria
UnitedHealthcare covers Wegovy for weight loss only when your employer or plan has added weight-loss drugs. Where it is covered, you need a BMI of 27 or more with a weight-related condition.
- For weight loss
- Plan dependent
- For type 2 diabetes
- Covered on formulary
- Prior authorization
- Required
- Weight rule
- A BMI of 27 or more with a weight-related condition
- Self-pay if denied
- $149 a month
Wegovy in brief
Its half-life is about 1 week. By 7 d, half is gone; five half-lives (35 d) leave about 3%.
STEP 1, 68 weeks: body weight fell 14.9%, compared with 2.4% on placebo.
Monthly prices in US dollars: the list price and self-pay offers, each taken from the maker's price page.
Sources: FDA label (DailyMed), healthsystemtracker.org, prnewswire.com 1 2.
Does UnitedHealthcare cover Wegovy?
| Medicine | Approved for | Status | Prior authorization |
|---|---|---|---|
| Wegovy | Weight loss, heart risk and MASH liver disease | Plan dependent | Required |
Sources: TrumpRx, NovoCare, CMS, medicare.gov.
The published policy
UnitedHealthcare is a commercial insurer
- Wegovy tablets: Typically excluded
- Program number: 2026 P 1114-23
Read the policy here: uhcprovider.com.
Source: uhcprovider.com.
Prior authorization checklist
- Diagnosis: Either the plan-required weight diagnosis or another approved Wegovy use appears in Your chart: MASH liver disease, heart risk
- You must meet BMI 27 or higher. The lower weight rule also requires a weight-related condition
- Records: The program for diet and activity that you tried, your height and weight as measured, and any weight-related conditions you have
- Who is responsible? Your prescriber submits the prior authorization, and you do not.
Source: uhcprovider.com.
Appeals after a denial
| Denial reason | What to send or ask |
|---|---|
| The plan excludes weight-loss drugs | This is a plan design choice. This decision is set by plan design. At renewal, ask the benefits team at your employer whether coverage for weight-loss drugs will begin in your plan. |
| Criteria not met | For a resubmission, ask your prescriber to include your measured BMI and every weight-related condition listed in your chart. The Eligibility requirement is BMI of 27 or more with a weight-related condition. |
| The drug is not on the plan's list | Find out which GLP-1 your plan prefers instead, and ask for a formulary exception. |
- The exact rule that was not met is named in the denial letter; get it.
- Your prescriber sends the appeal with chart notes that answer the rule.
- If the plan's own appeal does not succeed, ask for an independent external review.
What varies by state and by plan
| Plan | For weight loss | Prior authorization |
|---|---|---|
| Medicare | Bridge program only | Required |
| Medicaid | Varies by state | Required |
 Aetna | Employer option | Required |
 Cigna (Evernorth / Express Scripts) | Plan dependent | Required |
 Blue Cross Blue Shield | Plan dependent | Required |
 Kaiser Permanente | Plan dependent | Required |
 CVS Caremark | Plan sponsor choice | Required |
| VA (Veterans Health Administration) | Covered with criteria | Required |
 GEHA | Covered with PA | Required |
 Ambetter (Centene) | Excluded | Required |
| Express Scripts | Plan sponsor choice | Required |
| Optum Rx | Plan sponsor choice | Required |
 Humana | Bridge program only | Required |
| TRICARE | Prime and Select only | Required |
| ACA Marketplace plans | Rare | Required |
 Navitus | Plan sponsor choice | Not listed |
 Amerigroup (Elevance Medicaid) | Follows state Medicaid | Required |
For weight loss, 10 states now cover GLP-1s. See every state.
Other routes when coverage says no
| Route | Who it is for | What you pay |
|---|---|---|
| NovoCare Pharmacy: Wegovy pill 1.5 mg | Self-pay, no insurance needed | $149 a month |
| TrumpRx listing (pill, starting) | Self-pay only, not with insurance | $149 a month |
Prices checked November 2026. Every price links back to the page it came from.
Sources: TrumpRx, NovoCare, CMS, medicare.gov.