Insurance coverage · verified October 2026

Does Optum Rx cover Foundayo for weight loss?

It depends on your plan

Does Optum Rx cover Foundayo? It depends on your specific plan rather than on the Optum Rx name. Weight-loss drugs are usually a category your employer buys or declines, so two people holding Optum Rx cards can get opposite answers.

your employer's plan design decides, not the insurer's name · checked October 2026

Prior auth: required

Foundayo is covered for weight loss only when the employer or plan has chosen to cover weight-loss drugs. It was added to the UnitedHealthcare commercial criteria in May 2026, and Optum Rx runs prior authorization for those plans. In August 2026 the note that it was excluded at launch was removed. Approval needs a BMI of 30 or more, or 27 or more with a weight-related condition, plus lifestyle changes, and renewal after 6 months needs 5% weight loss.

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 Optum Rx 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: Not published in what we readLook Foundayo up in your plan's drug list or price tool, or call the number on your card.
BMI threshold: BMI 30+, or 27+ with a weight-related condition
“Body Mass Index (BMI) ≥ 30 kg/m2 or for pediatric patients a BMI > 95th percentile … BMI ≥ 27 kg/m2 -AND- (b) Patient has a weight-related comorbidity (e.g., dyslipidemia, hypertension, type 2 diabetes, sleep apnea)”
uhcprovider.com · 2026-10-01
Qualifying conditions: dyslipidemia, hypertension, type 2 diabetes, sleep apnea (examples listed)
“Body Mass Index (BMI) ≥ 30 kg/m2 or for pediatric patients a BMI > 95th percentile … BMI ≥ 27 kg/m2 -AND- (b) Patient has a weight-related comorbidity (e.g., dyslipidemia, hypertension, type 2 diabetes, sleep apnea)”
uhcprovider.com · 2026-10-01
Lifestyle program: Must be used alongside lifestyle changes such as diet, exercise or behavioral support
“Used as an adjunct to lifestyle modification (e.g., dietary or caloric restriction, exercise, behavioral support, community-based program)”
uhcprovider.com · 2026-10-01
Step therapy: Not published in what we readAsk whether another drug has to be tried before Foundayo.
Quantity limit: Supply limits may be in place
“Additional Clinical Rules: • Supply limits may be in place.”
uhcprovider.com · 2026-10-01
Renewal: First approval lasts 6 months; renewal needs 5% weight loss from baseline and continued lifestyle changes, then lasts 12 months
“Foundayo, Xenical or Zepbound: Authorization will be issued for 6 months. … Weight loss of ≥ 5% of baseline body weight for all other appetite suppressants”
uhcprovider.com · 2026-10-01
Plan can exclude it?: Yes: the program applies only to clients that elect to cover weight-loss drugs
“This is an optional program that is put in place for clients or businesses that have elected to cover weight loss products with Prior Authorization/Notification.”
uhcprovider.com · 2026-10-01
2026 change: Added to the criteria in May 2026; the note that it was excluded at launch was removed in August 2026
“5/2026 Added Foundayo and Wegovy HD to criteria. … 8/2026 Removed references to regulatory requirements as a new regulatory program is implementing. Removed footnote that Foundayo and Wegovy tablets are excluded at launch”
uhcprovider.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 · Optum Rx
This page is about the benefit manager itself. Optum Rx 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 Optum Rx 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: the program applies only to clients that elect to cover weight-loss drugs.
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: BMI 30+, or 27+ with a weight-related condition. Conditions: dyslipidemia, hypertension, type 2 diabetes, sleep apnea (examples listed). Lifestyle program: Must be used alongside lifestyle changes such as diet, exercise or behavioral support.
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: First approval lasts 6 months; renewal needs 5% weight loss from baseline and continued lifestyle changes, then lasts 12 months.

Get your real answer

Call the number on your pharmacy card and ask whether your employer or plan covers weight-loss drugs at all. If it does, your prescriber can request prior authorization through optumrx.com or the Optum Rx prior authorization line at 1-800-711-4555.

Coverage is plan-specific: this page reports what Optum Rx publishes, not a promise about your plan. Not medical or insurance advice.

What it actually costs you

If your plan covers it

The maker’s card is the lever. Foundayo Savings Card: $25 for a 1, 2 or 3-month fill. A month is 30 days. Government beneficiaries excluded.

If you are on Medicare, Medicaid or TRICARE For Life

The card is closed to you. Every manufacturer savings card in this category excludes government beneficiaries, and that is deliberate rather than an oversight you can argue around. The Medicare GLP-1 Bridge, at $50 a month, is the route worth asking about by name.

What Medicare covers, and what the Bridge does not count toward →

If the answer is no, or you have no plan

A copay card needs a copay to work on, so with no coverage it does nothing. That leaves the manufacturer’s own cash prices, the discount cards, and the compounded market, which is cheaper again and not FDA-approved. We priced all of them against each other.

Every route without insurance, priced →Whether GoodRx helps here →

All four manufacturers cap their cards differently. The caps compared side by side.

If Optum Rx says no

Read the denial letter for the reason first. Three different things get called a denial, and only two of them are worth appealing.

The plan excludes the category

Not a decision about you, so chart notes will not move it. The routes are a formulary exception, a different plan at open enrollment, or paying cash.

Step therapy

A sequence, not a refusal. Documented failure, intolerance or a reason you cannot take the first drug is the way through.

Criteria not met

The most winnable. It usually fails on missing paperwork, such as a BMI without a date or a lifestyle program with no records.

Which kind of no you got, and what each one needs →

Checklist · for the call

Questions to ask Optum Rx

Call the member services number on your card. Ask these in order, and write each answer down.

Is Foundayo on my plan's formulary for weight management, and at what tier?
Does my plan include the weight-loss medication benefit, or is that category excluded?
Does Foundayo need prior authorization? Can you send me the written criteria?
What BMI, and which conditions, does the policy require?
Do I have to show a diet, exercise or behavioral program first? For how long?
Do I have to try another drug first (step therapy)?
Is there a quantity limit on each fill?
How long does an approval last, and what does the renewal need?
What will I pay each month at the pharmacy once it is approved?
Which pharmacy do I have to use: retail, mail order or specialty?
If it is denied, how do I appeal, and what is the deadline?

Write down: date of call · name of the person · reference number · what they said

The receipts

Every claim on this page traces to Optum Rx’s own published material or a primary document, quoted verbatim, with the date we read it.

“This is an optional program that is put in place for clients or businesses that have elected to cover weight loss products with Prior Authorization/Notification.”