The facts
Weight loss
Plan-dependent
Type 2 diabetes
Not indicated
Prior auth
Required
Typical cost
Card to $25/mo, if covered
The criteria, as published
3 of 9 criteria are stated in the UnitedHealthcare 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 Zepbound up in your plan's drug list or price tool, or call the number on your card.
- BMI threshold
- Not published in what we readAsk member services for the written prior authorization criteria for Zepbound.
- Qualifying conditions
Moderate to severe obstructive sleep apnea (separate criteria)
“Zepbound is being requested for moderate to severe obstructive sleep apnea … Refer to Nonformulary Zepbound criteria for plans that do not cover weight loss medications.”
uhcprovider.com · effective 2026-07-01- Lifestyle program
- Not published in what we readAsk whether a diet, exercise or behavioral program has to be documented, and for how long.
- Step therapy
- Not published in what we readAsk whether another drug has to be tried before Zepbound.
- Quantity limit
- Not published in what we readAsk what quantity limit applies to each fill.
- Renewal
First approval lasts 6 months; renewal needs 5%+ weight loss from baseline
“Xenical or Zepbound: Authorization will be issued for 6 months. … Weight loss of ≥ 5% of baseline body weight for Zepbound”
uhcprovider.com · effective 2026-07-01- Plan can exclude it?
Yes: some plans do not cover weight-loss drugs; OSA has separate criteria
“Zepbound is being requested for moderate to severe obstructive sleep apnea … Refer to Nonformulary Zepbound criteria for plans that do not cover weight loss medications.”
uhcprovider.com · effective 2026-07-01- 2026 change
- Not published in what we readAsk whether Zepbound's status changed this year or changes at your next renewal.
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
No single PBM to name here, which is itself the finding. Different plans under this name use different benefit managers, so one national statement about the formulary would be wrong.
- 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 UnitedHealthcare 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: some plans do not cover weight-loss drugs; OSA has separate criteria.
- 2
Get the criteria in writing
Ask for the written prior authorization criteria for Zepbound, so your prescriber answers the plan's questions rather than guessing at them.
- 3
Your prescriber documents the clinical picture
Current and baseline BMI, with dates. Conditions: Moderate to severe obstructive sleep apnea (separate criteria). Records of any diet, exercise or behavioral program.
- 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. Our Zepbound prior authorization letter template covers the cover letter. 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.
Get your real answer
Price Zepbound in myuhc.com under Pharmacy → "Find and price medications." If not covered, call the number on your card and ask whether your employer elected the weight-loss benefit, and whether Zepbound is coverable under the obstructive sleep apnea criteria.
Coverage is plan-specific: this page reports what UnitedHealthcare publishes, not a promise about your plan. Not medical or insurance advice.
