The facts
Weight loss
Excluded
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 Wegovy pill 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 Wegovy pill.
- 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 5 months; renewal needs 5% weight loss from baseline, then lasts 12 months
“Wegovy injection or tablet*, Wegovy HD: Authorization will be issued for 5 months. … For Wegovy injection or tablet* and Wegovy HD weight loss of ≥ 5% of baseline body weight”
uhcprovider.com · 2026-10-01- Plan can exclude it?
Yes: Wegovy tablets are typically excluded from coverage
“* Wegovy tablets are typically excluded from coverage.”
uhcprovider.com · 2026-10-01- 2026 change
Added to the criteria in February 2026; since August 2026 marked as typically excluded
“2/2026 Updated to add Wegovy tablet and differentiate by indication. … added note that Wegovy tablets are typically excluded.”
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: Wegovy tablets are typically excluded from coverage.
- 2
Get the criteria in writing
Ask for the written prior authorization criteria for Wegovy pill, 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 5 months; renewal needs 5% weight loss from baseline, then lasts 12 months.
Get your real answer
Call the number on your pharmacy card and ask whether the Wegovy tablet is excluded on your plan. If it is, ask whether the Wegovy injection is covered instead, since it follows the same criteria.
Coverage is plan-specific: this page reports what Optum Rx publishes, not a promise about your plan. Not medical or insurance advice.
