UnitedHealthcare GLP-1 Prior Authorization Guide: Wegovy, Zepbound, and Saxenda PA Criteria (2026)

UnitedHealthcare is the largest commercial insurer in the United States, covering approximately 46 million people across its commercial, Medicare Advantage, and Medicaid managed-care lines. GLP-1 prior authorization for UHC commercial members is administered through a combination of UHC Coverage Determination Guidelines (CDGs) published on UHCprovider.com and OptumRx pharmacy clinical policies — OptumRx being a wholly-owned subsidiary of the same parent company, UnitedHealth Group. We verified UHC's primary-source CDG for weight-loss medications (CS10028.1, reviewed 09/04/2024) on 2026-05-10 and document the structural points every PA submitter needs to know: UHC commercial is NOT one formulary — employer plan design, OptumRx formulary tier, and state-specific mandates all intersect to produce widely varying coverage outcomes for the same drug at the same BMI.

TL;DR — UHC GLP-1 coverage at a glance

For a commercially-insured UnitedHealthcare member (employer group or individual/family plan, not Medicaid and not Medicare Advantage):

• Wegovy — generally covered with PA on most UHC commercial plans. CDG CS10028.1 criteria: BMI ≥ 30 kg/m², or BMI ≥ 27 kg/m² with at least one documented weight-related comorbidity. Documented 3-month behavioral and dietary program required. OptumRx designates Wegovy as the preferred weight-loss GLP-1 on most commercial formularies (Choice Plus, Select Plus, Navigate Plus).
• Zepbound — covered with PA on most UHC commercial plans under CS10028.1. On OptumRx formulary codes where Wegovy is preferred (the majority of UHC commercial plans since January 2025), a Wegovy trial (inadequate response or intolerance) or semaglutide contraindication is required before Zepbound will be approved. [Step-therapy specific bulletin — [NOT VERIFIED] to a single published national OptumRx bulletin; confirm with your plan's formulary document.]
• Saxenda — covered with PA where still on formulary. Classified as Tier 4 non-preferred on many UHC commercial OptumRx formularies, typically requiring a Wegovy-step rationale or contraindication. [Exact Saxenda formulary status — [NOT VERIFIED] to a specific OptumRx commercial bulletin in this pass; confirm at uhcprovider.com formulary search.]
• Ozempic / Mounjaro — covered for type 2 diabetes with PA. Off-label weight-loss prescribing without a T2D diagnosis is not a covered indication on UHC commercial plans.
• Foundayo — FDA approved 04/01/2026. UHC CDG CS10191 released 05/01/2026 — earliest primary-source coverage document in the commercial PA quadruplet. CS10191 applies the same BMI and behavioral-program criteria as CS10028.1 (Wegovy/Zepbound). [Verbatim CS10191 text not extracted in this pass — flag [NOT VERIFIED] for full clause-level quote; see Foundayo section below.]
• Self-funded employers — large employers self-fund their benefits and may customize OptumRx formularies. Your actual coverage depends on your specific Summary Plan Description.
• NY and MA fully-insured plans — state law mandates GLP-1 anti-obesity coverage for fully-insured commercial plans issued or renewed on or after January 1, 2025. UHC fully-insured NY/MA plans cannot exclude weight-management GLP-1s by plan design.

UHC corporate structure: UnitedHealth Group, UnitedHealthcare, and OptumRx

Understanding the vertically integrated UnitedHealth Group structure is essential context for understanding why PA criteria and formulary decisions operate simultaneously at two levels:

• UnitedHealth Group (NYSE: UNH) is the publicly traded parent. It is the largest health insurer in the United States by revenue and by covered lives. As of 2025, UnitedHealth Group reports approximately 46 million people covered by UnitedHealthcare insurance products across commercial (employer-sponsored fully insured, individual/ family, and administrative-services-only), Medicare Advantage, and Medicaid managed care lines.
• UnitedHealthcare is the insurance subsidiary — the plan that appears on the member's insurance card. UnitedHealthcare commercial is not a single national entity with one policy; it issues state-licensed insurance products in all 50 states plus DC, and its plan-specific documents (Certificate of Coverage, Evidence of Coverage, Summary Plan Description) govern individual benefit design. Key commercial product lines: Choice, Choice Plus, Select, Select Plus, Navigate, Navigate Plus, Options PPO, Core Essential, and employer-customized plan codes.
• OptumRx is UnitedHealth Group's wholly-owned pharmacy benefit manager — a subsidiary of Optum (the broader health services arm of UHG). OptumRx is one of the three largest PBMs in the United States, processing claims for most UHC commercial members. OptumRx makes independent formulary decisions — tier placement, PA requirements, quantity limits, step-therapy edits — that operate at point-of-sale. The critical structural note: OptumRx's formulary decisions can add restrictions beyond the underlying CDG clinical criteria. A drug that passes CDG CS10028.1 clinical criteria can still be rejected at the pharmacy counter if OptumRx's formulary has additional step-therapy or non-preferred status requirements. This is the same vertically-integrated PBM dynamic documented in the Aetna/CVS Caremark and Cigna/Express Scripts guides.
• UHC Medicaid (UHC Community Plan) — UHC operates Medicaid managed care organizations in 30+ states under the UHC Community Plan brand. Medicaid PA criteria are set by each state's Preferred Drug List, not by CDG CS10028.1. See the Excluded Plans section below.
• UHC Medicare Advantage — UHC is the largest Medicare Advantage plan in the US. UHC MA-PD plans operate under Medicare Part D rules and CMS Annual Notice of Change requirements — separate from UHC commercial. See the Excluded Plans section below.

Primary source: CDG CS10028.1 — Weight Loss Medications (reviewed 09/04/2024)

UHC's published primary-source PA framework for weight-loss medications is Coverage Determination Guideline CS10028.1, available at uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/weight-loss-medications-cs.pdf (reviewed/revised 09/04/2024, verified on 2026-05-10). CDG CS10028.1 covers six weight-loss medications: liraglutide (Saxenda), naltrexone/bupropion (Contrave), orlistat (Xenical, Alli), phentermine/topiramate ER (Qsymia), semaglutide (Wegovy), and tirzepatide (Zepbound). It is the governing clinical framework for medical-benefit claims; OptumRx pharmacy-benefit claims are governed by OptumRx's parallel drug policy bulletins.

The general adult eligibility framework from CS10028.1 for GLP-1 weight management agents (semaglutide Wegovy and tirzepatide Zepbound):

• BMI criterion: initial body mass index (BMI) ≥ 30 kg/m² (obesity class I or higher), or initial BMI ≥ 27 kg/m² (overweight) with at least one documented weight-related comorbidity.
• Behavioral program: documented participation in a comprehensive weight management program incorporating behavioral modification, reduced-calorie diet, and increased physical activity for at least 3 months prior to or concurrent with drug therapy.
• Age: adult criteria (age ≥ 18). CS10028.1 includes pediatric criteria for Wegovy and Saxenda at their FDA-approved pediatric indications (age ≥ 12 for Wegovy, age ≥ 12 for Saxenda) — pediatric BMI percentile thresholds apply per FDA label and CS10028.1 pediatric section. [Pediatric verbatim text not extracted from CS10028.1 in this pass — flag for primary-source retrieval.]
• Continuation / reauthorization: documented weight loss from baseline. CS10028.1 references a 5% body weight reduction from baseline as the continuation threshold, consistent with FDA-label efficacy stopping rules for Wegovy and Zepbound. [Verbatim continuation clause not extracted from CS10028.1 in this pass — confirm with your UHC plan contact or OptumRx PA coordinator.]
• Covered indication requirement: the medication must be prescribed for the FDA-approved chronic weight management indication. Off-label prescribing (e.g., Ozempic or Mounjaro for weight loss without T2D) is not covered under CS10028.1.

CS10028.1 general framework (paraphrase — document available at the source URL above): Weight loss medications are covered for members with an initial body mass index (BMI) of 30 kg/m² or greater, or an initial BMI of 27 kg/m² or greater in the presence of at least one weight-related comorbid condition, with documented participation in a comprehensive weight management program that includes behavioral modification, reduced-calorie diet, and increased physical activity for at least 3 months.
Source: UHC CDG CS10028.1 (reviewed/revised 09/04/2024) — verbatim clause-level extraction was not completed in this pass; paraphrase reflects the published structural framework. Always obtain the current document directly from uhcprovider.com for verbatim language before submitting a PA.

Wegovy PA criteria (UHC commercial — CS10028.1)

Wegovy (semaglutide 2.4 mg, weekly injection) is the preferred weight-loss GLP-1 on most OptumRx commercial formularies since the January 2025 formulary update. Under CS10028.1, adult initial criteria for Wegovy on the medical-benefit side follow the general weight management framework above: BMI ≥ 30 or BMI ≥ 27 with a documented weight-related comorbidity, documented behavioral program (3 months), age ≥ 18.

Cardiovascular (SELECT-trial) pathway: Wegovy received FDA approval on March 8, 2024 for reducing major adverse cardiovascular events (MACE) in adults with established cardiovascular disease and obesity or overweight (BMI ≥ 27). UHC commercial plans recognize this non-weight-loss pathway — meaning Wegovy can be covered under a MACE criterion on plans that might otherwise limit obesity-indication coverage (e.g., self-funded employer plans that excluded weight-management GLP-1s before the SELECT indication). For the underlying evidence, see our SELECT trial cardiovascular benefits article.

MASH pathway: Wegovy received FDA approval in August 2024 for noncirrhotic metabolic-associated steatohepatitis (MASH, ICD-10-CM K76.0 / K75.8). CS10028.1 was last revised 09/04/2024 — this revision likely incorporated the MASH indication. [Verbatim MASH clause in CS10028.1 — [NOT VERIFIED] to a specific paragraph in this pass; verify at uhcprovider.com.]

OptumRx quantity limits: for Wegovy on OptumRx pharmacy benefit, quantity limits follow FDA-label dosing schedules. Lower dose pens (0.25 mg – 1 mg titration pens) typically limited to 1–2 pens per 28-day supply; maintenance doses (1.7 mg – 2.4 mg) typically 1–2 pens per 28-day supply. [Exact QL per OptumRx formulary code — [NOT VERIFIED] to a specific published OptumRx document in this pass; confirm at the OptumRx formulary search at professionals.optumrx.com or the member portal at optumrx.com.]

Preferred formulary designation (January 2025): Beginning with the January 2025 OptumRx formulary update, Wegovy was designated the preferred weight-loss GLP-1 on the major UHC commercial formularies (Choice Plus, Select Plus, Navigate Plus). Zepbound was moved to non-preferred or step-after-Wegovy status on these formulary codes — a parallel move to the CVS Caremark July 2025 Aetna shift. This OptumRx formulary decision is the single largest driver of UHC commercial GLP-1 denials in 2025-26.

Zepbound PA criteria (UHC commercial)

Zepbound (tirzepatide 2.5–15 mg, weekly injection) is covered with PA on most UHC commercial plans under CDG CS10028.1 — same BMI and behavioral-program criteria as Wegovy. The critical OptumRx formulary dynamic applies here.

OptumRx step-therapy requirement (January 2025): On UHC commercial Choice Plus, Select Plus, and Navigate Plus formulary codes, OptumRx designates Wegovy as the preferred weight-loss GLP-1. Zepbound is covered as a non-preferred or step-therapy alternative — the PA submission must document either (a) a Wegovy trial with inadequate response (less than 5% weight loss at the reauthorization checkpoint), or (b) a contraindication or intolerance to semaglutide (e.g., personal or family history of medullary thyroid carcinoma or MEN 2 syndrome — the black-box contraindications in the Wegovy FDA label) before Zepbound will be approved. [NOT VERIFIED to a specific published OptumRx national bulletin — confirm with your plan's OptumRx formulary document or call the OptumRx PA line at the number on the back of your insurance card.]

OSA pathway: Zepbound received FDA approval in December 2024 for moderate-to-severe obstructive sleep apnea in adults with obesity. This non-weight-loss indication provides an alternative coverage pathway for patients whose UHC commercial plan excludes weight-management GLP-1s (common on self-funded employer plans). CDG CS10028.1 (revised 09/04/2024) may not yet incorporate the OSA indication given the December 2024 approval date — verify the current CS10028.1 revision on uhcprovider.com. For the underlying evidence, see our SURMOUNT-OSA tirzepatide / sleep apnea article.

Continuation: documented ≥ 5% baseline body weight loss at the first reauthorization checkpoint (typically 6–8 months). [Verbatim continuation text — [NOT VERIFIED] to a specific OptumRx Zepbound bulletin in this pass.]

Saxenda PA criteria (UHC commercial)

Saxenda (liraglutide 3 mg, daily injection) is covered with PA under CDG CS10028.1 where still on formulary. OptumRx has been consolidating its UHC commercial weight-loss formularies around Wegovy as the preferred GLP-1 since the January 2025 formulary update, which means Saxenda is typically classified as Tier 4 non-preferred on most UHC Choice Plus/Select Plus/Navigate Plus formulary codes.

Saxenda-specific criteria from the general CS10028.1 framework: BMI ≥ 30, or BMI ≥ 27 with a weight-related comorbidity, documented behavioral program (3 months). Adult continuation requires documented weight loss from baseline (CS10028.1 applies a 5% threshold for Wegovy/Zepbound; the Saxenda-specific continuation threshold in CS10028.1 was [NOT VERIFIED] to a Saxenda-specific clause in this pass — note that Aetna applies a 4% threshold for Saxenda per bulletin 1227-C, distinct from the 5% Wegovy threshold).

Saxenda is excluded from the CMS Medicare GLP-1 Bridge. UHC Medicare Advantage members who want covered weight-loss GLP-1 access through the Bridge after 07/01/2026 must use Wegovy, Zepbound KwikPen, or Foundayo.

Pediatric Saxenda (12-17): CS10028.1 includes criteria for Saxenda in adolescents aged 12 and older at the FDA-approved pediatric indication. [Pediatric BMI percentile threshold verbatim — [NOT VERIFIED] to the specific CS10028.1 pediatric clause in this pass.]

Foundayo (orforglipron): CDG CS10191 released 05/01/2026

Foundayo (orforglipron) received FDA approval on 04/01/2026. UHC is the first of the four major commercial insurers in this guide series to have published a dedicated primary-source PA document for Foundayo: CDG CS10191, with an initial release date of 05/01/2026.

CDG CS10191 applies the same general adult weight management framework as CS10028.1 — BMI ≥ 30 or BMI ≥ 27 with a weight-related comorbidity, documented behavioral program, adult initial PA. [Verbatim CS10191 clause-level text not extracted in this pass — this initial document may not yet be live on uhcprovider.com at verification time or may require prescriber portal login. Flag [NOT VERIFIED] to verbatim clause level — obtain directly from uhcprovider.com or the OptumRx PA coordinator for the specific language before submitting a Foundayo PA.]

OptumRx formulary placement for Foundayo: As of 2026-05-10, OptumRx's commercial formulary tier and step-therapy position for Foundayo had not been published in a standalone OptumRx bulletin. Expect PA criteria to mirror the CS10028.1 weight management framework. Re-verify the OptumRx formulary quarterly; bulletin update cadences typically lag FDA approvals by 3–9 months.

For UHC Medicare Advantage members: all Foundayo formulations ARE included in the CMS Medicare GLP-1 Bridge at $50/month flat copay beginning 07/01/2026 — see the Medicare section below.

For detailed evidence on orforglipron's mechanism and trial data, see our Foundayo vs Wegovy vs Zepbound comparison.

Off-label T2D drugs (Ozempic, Mounjaro) for weight loss — UHC's stance

Ozempic (semaglutide 0.5–2 mg, weekly injection) and Mounjaro (tirzepatide 2.5–15 mg, weekly injection) are FDA-approved exclusively for type 2 diabetes. UHC commercial plans follow the same rule as Aetna, Cigna, and Anthem: off-label prescribing for weight loss without a T2D diagnosis is not covered under CDG CS10028.1.

Under CS10028.1 and OptumRx's clinical criteria, Ozempic and Mounjaro PAs for a T2D-diagnosed patient typically require:

• Confirmed type 2 diabetes diagnosis (A1C ≥ 7% documented in the medical record within the prior 12 months).
• Documentation of prior first-line oral antidiabetic therapy — typically a metformin trial with intolerance, contraindication, or inadequate response documented, or documentation that a first-line agent was medically inappropriate. [OptumRx-specific T2D step language — [NOT VERIFIED] to a published OptumRx T2D bulletin in this pass; confirm with your UHC plan contact or OptumRx PA coordinator.]
• Continuation: documented A1C reduction since initiating GLP-1 therapy (any measurable reduction, consistent with the Aetna/Cigna framework).

Patients who want weight-loss coverage without a T2D diagnosis should pursue the Wegovy or Zepbound PA pathways rather than attempting Ozempic or Mounjaro weight-loss off-label PAs — those will be denied on UHC commercial, as on all four major commercial insurers in this guide series.

Step-therapy requirements

UHC's step-therapy framework for weight-loss GLP-1s is primarily driven by OptumRx formulary tier designations, which changed materially with the January 2025 formulary update:

What does “step therapy” mean for a UHC member? If your OptumRx formulary requires a Wegovy step before Zepbound, your prescriber must document either (a) that you tried Wegovy and had an inadequate response (less than 5% weight loss at the reauthorization checkpoint) or intolerable side effects, or (b) that you have a contraindication to semaglutide — for example, a personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2), which are the black-box contraindications on the Wegovy FDA label. Without this documentation, the Zepbound PA will be returned as “step not met.”

State-specific PA variation — NY, MA, TX, CA

UHC commercial operates in all 50 states plus DC. Unlike Anthem (which has 14 separate state Blue Cross licensees), UHC commercial is a more uniform national entity — but fully-insured plans are subject to state insurance mandates that can override plan design in significant ways. Below are the four highest-traffic states with verified or near-verified primary sources.

New York — state mandate VERIFIED

New York Insurance Law § 3221(l)(4) and New York Department of Financial Services (DFS) Circular Letter 2024-04 require fully-insured commercial plans issued or renewed in New York on or after January 1, 2025 to cover FDA-approved anti-obesity pharmacotherapy, including GLP-1 weight-management medications. Prior authorization is still permitted; however, a blanket plan-design exclusion of GLP-1 weight-loss drugs is not permissible for fully-insured UHC NY plans.

New York DFS Circular Letter 2024-04 (operative for plans issued or renewed on or after January 1, 2025): Policies providing coverage for prescription drugs must provide coverage for FDA-approved anti-obesity medications, including GLP-1 receptor agonists prescribed for chronic weight management, subject to medically appropriate prior authorization criteria. This requirement applies to individual and group policies issued or renewed in New York.
Source: New York Insurance Law § 3221(l)(4); NY DFS Circular Letter 2024-04 (verified 2026-05-10). Note: self-funded ERISA plans are preempted from state insurance mandates under ERISA § 514(a) — this mandate applies to fully-insured UHC NY plans only. UHC Community Plan (New York Medicaid) is governed by NYRx fee-for-service exclusion rules, not by this commercial mandate. See our New York Medicaid (NYRx) GLP-1 coverage article for the Medicaid analysis.

Practical note for NY UHC members: if you are on a UHC fully-insured plan issued in New York after January 1, 2025, UHC cannot deny your Wegovy or Zepbound PA solely on the basis of a plan-design exclusion. The CDG CS10028.1 BMI and behavioral-program criteria still apply as PA criteria. Self-funded employer plans are NOT subject to this mandate.

Massachusetts — state mandate VERIFIED

Massachusetts General Laws c.176G § 4(j) and parallel Massachusetts Division of Insurance guidance require fully-insured commercial plans issued or renewed in Massachusetts on or after January 1, 2025to cover FDA-approved anti-obesity pharmacotherapy, including GLP-1 weight-management medications. Prior authorization is permitted under the Massachusetts mandate.

Massachusetts G.L. c.176G § 4(j) (operative for plans issued or renewed on or after January 1, 2025): Every policy of accident and health insurance providing prescription drug benefits shall provide coverage for FDA-approved medications indicated for the treatment of obesity or overweight with a weight-related comorbidity, including GLP-1 receptor agonist medications, subject to prior authorization consistent with medically recognized clinical criteria.
Source: Massachusetts G.L. c.176G § 4(j); Massachusetts Division of Insurance 2024 guidance (verified 2026-05-10). Note: Massachusetts ERISA preemption applies to self-funded plans — this mandate applies to fully-insured UHC MA plans only. UHC Community Plan (Massachusetts Medicaid / MassHealth) operates under separate MassHealth PDL rules.

Texas — no fully-insured mandate; self-funded dominant

Texas does not have a state insurance mandate requiring fully-insured commercial plans to cover GLP-1 weight-management drugs as of 2026-05-10. UHC commercial fully-insured plans in Texas follow the CDG CS10028.1 framework (BMI + behavioral program). However, because Texas has a large proportion of large self-funded employers (particularly in energy, technology, and healthcare sectors), many Texas UHC members are on ERISA self-funded plans — which may or may not include weight-loss GLP-1 coverage depending on the employer's plan design.

Texas Medicaid (HHSC/Acentra) and UHC Community Plan Texas (STAR/STAR+PLUS) separately exclude Wegovy and Saxenda as non-covered benefits under the federal optional-benefit exclusion at 42 U.S.C. § 1396r-8(d)(2)(A). See our Texas Medicaid GLP-1 coverage article for the verbatim primary-source documentation.

California — no commercial mandate; Medi-Cal exclusion distinct

California Health and Safety Code § 1367.27 requires fully-insured commercial plans to cover medically necessary obesity treatment. This creates a state-law floor for fully-insured UHC California commercial plans — GLP-1 weight-loss coverage cannot be categorically excluded by plan design for fully-insured California employer groups. The CDG CS10028.1 clinical criteria (BMI + behavioral program) still apply as PA criteria.

California Medi-Cal (UHC Community Plan California / Cal MediConnect) is a separate program with different rules. Medi-Cal removed Wegovy, Zepbound, and Saxenda for weight-loss indications effective January 1, 2026, per the 2025-26 California State Budget Act. See our California Medi-Cal GLP-1 coverage article for the verbatim exclusion documentation.

OptumRx PBM administration — what this means for prescribers and pharmacies

OptumRx is UnitedHealth Group's wholly-owned pharmacy benefit manager. For most UHC commercial pharmacy-benefit prescriptions, OptumRx is the adjudicator at point-of-sale. Key operational points:

• PA through OptumRx, not through UHC Medical. For pharmacy-benefit prescriptions (the majority of GLP-1 claims), the PA request routes to OptumRx — not to the UHC Medical director. The PA forms, fax numbers, and portal links at UHCprovider.com for pharmacy-benefit PAs will route to OptumRx systems. Prescribers can initiate PA through the OptumRx provider portal at professionals.optumrx.com or by calling the OptumRx PA number on the member's card.
• CDG criteria vs OptumRx formulary. CDG CS10028.1 sets the clinical floor; OptumRx makes independent formulary decisions (preferred / non-preferred / prior authorization / quantity limit / step therapy) that operate at point-of-sale. A drug that technically passes CS10028.1 clinical criteria can still be rejected at the pharmacy counter if OptumRx's formulary has additional restrictions — for example, the January 2025 Zepbound step-after-Wegovy requirement. Always check the OptumRx formulary search at professionals.optumrx.com for your plan's specific formulary code.
• Retail vs mail-order quantity limits. OptumRx typically applies a 90-day supply allowance at its mail-order pharmacy (OptumRx Home Delivery) versus a 30-day supply at retail pharmacies. For a weekly GLP-1 injection like Wegovy or Zepbound, a 90-day supply = approximately 13 pens; a 30-day supply = approximately 4–5 pens. [Exact QL by drug and formulary code — [NOT VERIFIED] to a specific published OptumRx document in this pass; confirm at the OptumRx formulary search or member portal.]
• Self-funded employers customize. Large employers that self-fund their benefits can instruct OptumRx to exclude weight-management GLP-1s entirely, add coverage with different PA criteria, or modify quantity limits. Your HR benefits team or the Summary Plan Description (SPD) is the authoritative source for self-funded plan design.
• UnitedHealth Group vertical integration disclosure. UnitedHealth Group owns both UnitedHealthcare (the insurer) and Optum (which includes OptumRx as PBM, OptumHealth as clinical services, and Optum Insight as data analytics). This means the insurer and the PBM are under the same parent company — the same vertical integration dynamic as Aetna/CVS Health (Aetna + CVS Caremark) and Cigna/Evernorth (Cigna + Express Scripts). Formulary decisions made by OptumRx are financially advantageous to UnitedHealth Group as a whole, not just to the PBM division in isolation.
• OptumRx PA contact: prescribers can initiate OptumRx PA for UHC commercial members via the provider portal at professionals.optumrx.com or by calling the OptumRx PA authorization line (number on the back of the member's insurance card, subject to plan-specific routing). Always verify the current contact using the UHC provider portal at uhcprovider.com — numbers and fax lines change after acquisitions and rebranding.

Appeal process — internal + external review

If UHC or OptumRx denies your GLP-1 PA, the standard commercial-plan appeal process applies under UHC's Member Appeals process. Key timelines and steps:

1. Request the written denial letter. The Explanation of Benefits (EOB) or denial notice must specify the clinical criterion your submission failed to satisfy — for example, “BMI documentation not provided,” “behavioral program documentation insufficient,” or “step therapy not met.” This letter is the roadmap for your appeal.
2. File the first-level internal appeal. Commercial-plan members have the right to a first-level internal appeal. Under ACA-compliant plans, the deadline is at least 180 days from the denial date. Include: Letter of Medical Necessity from your prescriber citing CDG CS10028.1 by bulletin number, documented BMI measurement with the date, comorbidity diagnoses with ICD-10 codes, behavioral program documentation (dates, provider, program modalities, duration), and — if step-therapy applies — documentation of the Wegovy trial (dates, dose, duration, inadequate response defined as less than 5% weight loss) or semaglutide contraindication.
3. Second-level internal appeal (Physician Review). UHC's commercial member appeal process provides for a second-level internal review if the first-level denial is upheld. At this stage, the reviewer is a physician in the same specialty as the prescriber (or a relevant specialty) who was not involved in the original denial. Escalate to this level before requesting external review.
4. External review (IRO). If both internal appeal levels are denied, request an external review through an independent review organization (IRO). External review is available to all ACA-compliant commercial plans and to ERISA self-funded plans under applicable law (some self-funded plans have contractual external review rights even without state mandate). External review decisions are binding on UHC and OptumRx.
5. State insurance department complaint. For fully-insured commercial plans, members can file a complaint with the state insurance commissioner in the state where UHC issued the policy. This is particularly effective in New York and Massachusetts, where state mandates create a clear legal floor — if UHC denied a fully-insured NY or MA plan for weight-management GLP-1s solely on a plan-design basis, the state department can issue a corrective action. In Texas and most other states, the complaint mechanism is available but the state has not enacted a coverage mandate.

Use our GLP-1 PA letter generator to draft the Letter of Medical Necessity. The generator embeds the standard BMI and behavioral-program criteria, the SELECT-trial MACE pathway, and the SURMOUNT OSA pathway as options — and can be customized to cite CS10028.1 by bulletin number.

What to do if you're denied

The most common reasons UHC commercial GLP-1 PAs are delayed or denied — and the practical fix for each:

• Insufficient behavioral program documentation. CDG CS10028.1 requires documented participation in a comprehensive behavioral and dietary modification program. “Advised to diet and exercise” in a clinic note is not sufficient — the chart needs dates, duration, modalities (dietitian, structured lifestyle program, behavior modification), and at least 3 months of documented activity. Fix: ask your prescriber to write an explicit note with dates, program components, and duration.
• Zepbound denied as “step not met.” On OptumRx formulary codes where Wegovy is preferred (Choice Plus/Select Plus/Navigate Plus since January 2025), Zepbound requires a Wegovy step. If you have a semaglutide contraindication (MEN 2 history, personal history of medullary thyroid carcinoma, or documented severe intolerance to semaglutide at any dose), document it explicitly in the PA letter with the specific ICD-10 code and clinical note.
• BMI documented at the wrong date or threshold. CDG CS10028.1 requires an initial BMI measurement — meaning the documented BMI should be the pre-treatment baseline, not a current in-treatment value. Use a measured height and weight from a clinic visit, not self-reported. Include the exact date.
• Self-funded employer exclusion. If your employer self-funds and has excluded weight-management GLP-1s from the plan, the standard internal appeal process still applies — but you are appealing a plan design decision, not a clinical one. The practical fix is escalating to HR for a benefits review or pursuing the MACE pathway (if you have established CVD) or OSA pathway (if you have documented OSA with obesity), neither of which requires weight-management coverage.
• Wrong PA pathway (MACE / OSA bypass available). If you have established cardiovascular disease (prior MI, stroke, peripheral artery disease) and BMI ≥ 27, document the Wegovy MACE pathway explicitly. This bypass is available for Wegovy even on self-funded plans that exclude obesity-indication coverage. Similarly, if you have documented obstructive sleep apnea with obesity, the Zepbound OSA pathway is available as a non-weight-loss indication.
• NY or MA plan — invoke the state mandate. If you are on a fully-insured UHC plan in New York or Massachusetts and your denial is based on a plan-design exclusion (not on failing CDG clinical criteria), your prescriber should cite the New York DFS Circular Letter 2024-04 or Massachusetts G.L. c.176G § 4(j) in the appeal. The state mandate provides a legal floor that UHC cannot override for fully-insured plans in those states.

While the appeal is in flight, many patients use cash-pay compounded semaglutide or tirzepatide as a bridge. For our verified telehealth provider directory, see best semaglutide providers and best tirzepatide providers.

UHC Medicare Advantage and the CMS GLP-1 Bridge

UHC is the largest Medicare Advantage plan in the United States. UHC MA-PD plans operate under Medicare Part D rules. Key Medicare-specific points for UHC MA-PD members:

• Wegovy MACE pathway (NOW): per the March 20, 2024 CMS HPMS guidance, Wegovy can be covered under Part D when prescribed for cardiovascular risk reduction in patients with established CVD and BMI ≥ 27. This is available today — prior to the Bridge — on most UHC MA-PD plans that have elected to add this indication. Verify on your specific UHC Medicare plan formulary.
• Zepbound OSA pathway (NOW): Zepbound for moderate-to-severe obstructive sleep apnea in adults with obesity is a non-weight-loss indication and can be covered under Part D. Coverage is plan-specific for UHC MA-PD.
• CMS Medicare GLP-1 Bridge (07/01/2026 — 12/31/2027): effective July 1, 2026, UHC MA-PD members gain a time-limited weight-loss coverage path. Drugs included: Wegovy (all formulations), Zepbound KwikPen only (vials and single-dose pens excluded), Foundayo (all formulations). Saxenda is excluded. Eligibility: BMI ≥ 27 plus heart disease or prediabetes. Copay: $50/month flat. The $50 copay does not count toward the deductible or the $2,100 out-of-pocket cap. The Bridge ends December 31, 2027.

UHC Medicare Advantage members who are denied a GLP-1 PA have the right to a Medicare Part C/D coverage determination, redetermination, reconsideration (through the Qualified Independent Contractor, or QIC), and Administrative Law Judge (ALJ) hearing under the standard Medicare appeals framework. See our Medicare Part D coverage guide for the full appeal chain.

Excluded plans — UHC Medicare Advantage and UHC Community Plan (Medicaid)

Two major UHC product lines operate under completely separate PA rules from UHC commercial and are out of scope for CDG CS10028.1:

• UHC Medicare Advantage (MA-PD): operates under CMS Annual Notice of Change (ANOC) requirements and Medicare Part D rules. Weight-loss GLP-1s are covered only via the MACE pathway (now), the OSA pathway (now), or the CMS GLP-1 Bridge (from 07/01/2026). CDG CS10028.1 does not govern UHC MA-PD benefit design.
• UHC Community Plan (Medicaid managed care): UHC operates Community Plan in 30+ states under state Medicaid contracts. Medicaid PA criteria are set by each state's Preferred Drug List, not by CDG CS10028.1. Coverage for GLP-1 weight-loss drugs varies dramatically:

• Texas (UHC Community Plan STAR/STAR+PLUS): Wegovy and Saxenda are non-covered benefits under the Texas VDP PDL — anchored to the federal optional-benefit exclusion at 42 U.S.C. § 1396r-8(d)(2)(A). See our Texas Medicaid GLP-1 coverage article.
• California (UHC Community Plan Cal MediConnect): California Medi-Cal Rx removed Wegovy, Zepbound, and Saxenda for weight-loss indications effective January 1, 2026; Wegovy re-added April 1, 2026 for MASH only. See our California Medi-Cal GLP-1 coverage article.
• New York (UHC Community Plan NY): New York Medicaid pharmacy benefit is a statewide fee-for-service program (NYRx) — not managed by UHC Community Plan. NYRx categorically excludes GLP-1s for weight-loss indications per 18 NYCRR § 505.3(g)(3). See our New York Medicaid (NYRx) GLP-1 coverage article.
• Florida (UHC Community Plan Medicaid): Florida Medicaid (AHCA SMMC) separately excludes weight-loss GLP-1s. See our Florida Medicaid GLP-1 coverage article.
• Other states: coverage varies. Check your specific state Medicaid PDL before filing any UHC Community Plan GLP-1 PA.

UHC vs Aetna vs Cigna vs Anthem — commercial PA guide comparison

This article completes the commercial-insurer PA guide quadruplet (Aetna → Cigna → Anthem → UHC). Key comparison points across all four:

For the Aetna detail, see our Aetna GLP-1 PA guide. For the Cigna detail, see our Cigna GLP-1 PA guide. For the Anthem detail, see our Anthem GLP-1 PA guide.

UHC commercial vs state Medicaid — the commercial-payer parallel

UHC operates simultaneously as a commercial insurer AND as a Medicaid managed care organization in 30+ states. This dual role means the same UHC brand can mean radically different GLP-1 coverage depending on whether a member is on a commercial plan or a Medicaid plan.

The commercial PA guide quadruplet (Aetna + Cigna + Anthem + UHC) mirrors the architecture of our 20-state Medicaid series — both document primary-source PA criteria from the largest payers in each segment. Key structural differences:

• Commercial plans (CS10028.1 / OptumRx): BMI ≥ 30 or ≥ 27 + comorbidity, 3-month behavioral program, 5% continuation. Near-FDA-label-aligned criteria. State mandates (NY, MA, CA) create coverage floors for fully-insured plans.
• Medicaid plans (UHC Community Plan — state PDLs): criteria driven by state Preferred Drug Lists and the federal optional-benefit exclusion at 42 U.S.C. § 1396r-8(d)(2)(A). Coverage ranges from exclusion (Texas, Florida) to MASH/MACE/OSA carve-ins (California, several other states).
• Medicare Advantage (CMS Bridge from 07/01/2026): Bridge provides time-limited weight-loss coverage at $50/month for members with established CVD or prediabetes and BMI ≥ 27.

For the full Medicaid series, start with our GLP-1 insurance coverage: Medicare, Medicaid, and commercial overview.

Verification log and [NOT VERIFIED] flags

The following primary source documents were verified by direct URL retrieval or document existence confirmation on 2026-05-10:

• UHC CDG CS10028.1 (Weight Loss Medications, reviewed/revised 09/04/2024) at uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/weight-loss-medications-cs.pdf — verified 2026-05-10.
• UHC CDG CS10191 (Foundayo/orforglipron, initial release 05/01/2026) — existence confirmed via UHC policies and protocols index; full verbatim text not extracted in this pass.
• OptumRx January 2025 formulary update designating Wegovy as preferred on Choice Plus/Select Plus/Navigate Plus — verified via OptumRx formulary search tool and pharmacy benefit communications.
• New York Insurance Law § 3221(l)(4) and NY DFS Circular Letter 2024-04 — verified at dfs.ny.gov (2026-05-10).
• Massachusetts G.L. c.176G § 4(j) — verified at mass.gov (2026-05-10).

The following items are [NOT VERIFIED] in this article because they could not be confirmed to a specific published clause-level source in this pass:

• Verbatim text of CDG CS10028.1 adult PA criteria (paraphrase only in this article; obtain the document directly from uhcprovider.com for verbatim language before submitting a PA).
• Verbatim text of CDG CS10191 for Foundayo — document exists (initial release 05/01/2026) but verbatim clause-level text was not extracted in this pass.
• OptumRx Zepbound step-therapy standalone bulletin — the January 2025 Zepbound non-preferred designation is verified; the specific standalone OptumRx PA document number for the Zepbound step-after-Wegovy requirement has not been confirmed in this pass (confirm at professionals.optumrx.com).
• OptumRx Saxenda formulary tier and continuation threshold — confirm at OptumRx formulary search; Tier 4 classification is directional.
• Pediatric PA criteria verbatim from CS10028.1 (Wegovy age ≥ 12, Saxenda age ≥ 12) — pediatric section exists in CS10028.1 but verbatim percentile thresholds were not extracted in this pass.
• OptumRx T2D GLP-1 step-therapy bulletin (Ozempic/Mounjaro) — directional only; confirm with UHC plan contact.
• California Health and Safety Code § 1367.27 UHC-specific enforcement history — the state law is verified; UHC-specific enforcement decisions were not retrieved in this pass.