The facts
Weight loss
Plan-dependent
Type 2 diabetes
Not indicated
Prior auth
Required
Typical cost
Plan-specific
The criteria, as published
7 of 9 criteria are stated in the CVS Caremark documents we read. Tap a row for the exact wording. Where a cell says not published, the documents we read do not say, and the line under it is how to find out.
- Formulary status
Preferred brand (PB) on the 2026 Standard Control plan drug guide (Aetna edition, Oct 2026)
“PB = Preferred Brands … FOUNDAYO ORAL TABLET 0.8 MG, 14.5 MG, 17.2 MG, 2.5 MG, 5.5 MG, 9 MG (orforglipron-weight management) PB”
fm.formularynavigator.com · 2026 plan year- BMI threshold
Baseline BMI 35+ in Aetna's published 'BMI 35' version of the criteria
“Reduction in Excess Body Weight, Maintenance of Weight Reduction Long Term (Adult) … The patient is 18 years of age or older. … The patient has a baseline body mass index (BMI) greater than or equal to 35 kg/m”
aetna.com · 2026-04-10- Qualifying conditions
- Not published in what we readAsk which conditions the Foundayo criteria accept alongside BMI.
- Lifestyle program
At least 6 months in a weight management program with diet, activity and behavior change before starting
“The patient has participated in a comprehensive weight management program that encourages behavioral modification, reduced-calorie diet, AND increased physical activity with continuing follow-up for at least 6 months prior to using drug therapy.”
aetna.com · 2026-04-10- Step therapy
- Not published in what we readAsk whether another drug has to be tried before Foundayo.
- Quantity limit
30 tablets per 25 days, or 90 per 75 days
“Foundayo (orforglipron) 0.8 mg, 2.5 mg, 5.5 mg, 9 mg, 14.5 mg, 17.2 mg 30 tablets / 25 days 90 tablets / 75 days”
aetna.com · 2026-04-10- Renewal
After 3 months on a stable maintenance dose, at least 5% of starting weight lost, or that loss kept off
“If the request is for Wegovy (semaglutide), tirzepatide (Zepbound/Mounjaro), or Foundayo (orforglipron), then ALL of the following criteria are met: The patient has completed at least 3 months of therapy with the requested drug at a stable maintenance dose. The patient has lost at least 5 percent of baseline body weight OR the patient has continued to maintain their initial 5 percent weight loss.”
aetna.com · 2026-04-10- Plan can exclude it?
Yes: plan sponsors that use Caremark formularies can customize coverage
“Plan sponsors that adopt CVS Caremark template formularies retain discretion to customize coverage for their members.”
cvshealth.com · 2026-05-28- 2026 change
Moved from non-preferred to preferred on the Standard Control formulary Oct 1, 2026
“Formulary Updates for Standard Control Formulary™ effective October 1, 2026 … These products will move from non-preferred to preferred: … Endocrine and Metabolic, Antiobesity FOUNDAYO”
aetna.com · 2026-10-01
Who actually decides this
Not the logo on your card, most of the time. Three parties sit between you and the answer, and knowing which one is saying no tells you who to ask.
- 1
The pharmacy benefit manager · CVS Caremark
This page is about the benefit manager itself. CVS Caremark builds the formularies, so what is preferred, excluded or subject to step therapy on them is its decision. Which of its formularies you get, and whether weight-loss drugs are on your plan at all, is your plan sponsor’s choice.
- 2
Your employer, if the plan comes through work
Weight-loss drugs are usually a category an employer buys or declines, not something the insurer includes by default. That is why two people holding identical cards get opposite answers, and why the useful question for member services is whether your plan includes the weight-loss medication benefit at all, before anything about criteria.
How prior authorization works here
Six steps. Specifics come from the criteria above; where CVS Caremark does not publish one, the step says what to ask for.
- 1
Confirm the benefit exists
Before any paperwork, ask whether your plan includes the weight-loss drug benefit. On whether a plan can leave it out, the documents say: Yes: plan sponsors that use Caremark formularies can customize coverage.
- 2
Get the criteria in writing
Ask for the written prior authorization criteria for Foundayo, so your prescriber answers the plan's questions rather than guessing at them.
- 3
Your prescriber documents the clinical picture
BMI: Baseline BMI 35+ in Aetna's published 'BMI 35' version of the criteria. Any weight-related conditions, with diagnosis codes. Lifestyle program: At least 6 months in a weight management program with diet, activity and behavior change before starting.
- 4
Answer step therapy, if there is any
Ask whether another drug must come first. If you have already tried one, the request should list it with dates and the reason it stopped.
- 5
Submit, then track it
Your prescriber sends the plan’s form with the notes. Write down the date and the reference number, and ask how you will hear back.
- 6
Plan for the renewal
What the documents say: After 3 months on a stable maintenance dose, at least 5% of starting weight lost, or that loss kept off.
Get your real answer
Sign in at Caremark.com and open Plan Summary under Plan & Benefits to see whether your employer covers weight-loss drugs. If it does, ask your prescriber to send the prior authorization with your starting BMI, your weight-related conditions and your diet and exercise history.
Coverage is plan-specific: this page reports what CVS Caremark publishes, not a promise about your plan. Not medical or insurance advice.
