Optum Rx (UnitedHealthcare)
PBM standard commercial template (Premium Standard Formulary) · updated August 8, 2026
Coverage right now
- Foundayo™ (orforglipron) Unknown
- Saxenda® (liraglutide) Covered
- Wegovy® (semaglutide injection) Covered
- Wegovy® tablets (oral semaglutide) Covered
- Zepbound® (tirzepatide) Covered
Kept both Wegovy and Zepbound covered throughout 2025-2026 — no CVS-style exclusion — but both sit at Tier 3 (non-preferred brand) with PA + quantity limits. Weight-loss coverage is an opt-in employer benefit. Foundayo not yet listed as of the retrieved 2026 documents.
Drug status
| Drug | Status | Detail | Confidence |
|---|---|---|---|
| Zepbound® (tirzepatide) | Covered from Jan 1, 2026 | Tier 3, PA + QL on the 2026 Premium Standard Formulary. OSA pathway added July 2025 (policy P 1475-1: sleep study + CPAP requirements). source | high |
| Wegovy® (semaglutide injection) | Covered from Jan 1, 2026 | Tier 3, PA + QL. source | high |
| Wegovy® tablets (oral semaglutide) | Covered from Jul 1, 2026 | Covered under the UHC weight-loss PA policy (P 1114-21 covers Wegovy injection and tablet); tier placement not shown in the Jan 2026 booklet. source | medium |
| 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. source | low |
| Saxenda® (liraglutide) | Covered from Jan 1, 2026 | Tier 3, PA + QL. source | high |
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) 5 · Zepbound 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
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).
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.