UnitedHealthcare's updated weight-loss prior authorization program takes effect

UnitedHealthcare's updated prior authorization program for weight-loss and appetite-suppression drugs, numbered 2026 P 1114-22, carries an effective date of 9/1/2026 ^[1]. The document sets out who qualifies, how long a first approval lasts and what has to be documented to keep coverage going.

The program covers a long list of products: phentermine (including Adipex-P and Lomaira), benzphetamine, diethylpropion, phendimetrazine, Contrave (naltrexone/bupropion), orlistat (Xenical), Qsymia (phentermine and topiramate extended-release), Saxenda (liraglutide), Wegovy (semaglutide) injection, Wegovy (semaglutide) tablet, Wegovy HD (semaglutide), Zepbound (tirzepatide) and Foundayo (orforglipron) ^[1]. Both brand and generic versions and all formulations are included unless noted otherwise ^[1].

One important caveat: this is described as an optional program used by clients or employers that have chosen to cover weight-loss products with prior authorization. It is also designed to meet regulatory requirements for coverage of weight-loss medications in California, New Mexico, North Dakota Essential Health Benefits plans and New York ^[1]. For plans that do not cover weight-loss drugs at all, the policy points to separate "Nonformulary Wegovy" and "Nonformulary Zepbound" criteria ^[1].

What the criteria require

For an initial approval under the general criteria, a patient must meet all of several conditions. The request has to be for appetite suppression or weight loss, or for one of the non-weight indications listed: Wegovy injection or tablet for reducing major adverse cardiovascular events in people with established cardiovascular disease (prior heart attack, ischemic or hemorrhagic stroke, or peripheral arterial disease); Wegovy injection for metabolic dysfunction-associated steatohepatitis (MASH) with moderate to advanced fibrosis (stage F2 or F3); or Zepbound for moderate to severe obstructive sleep apnea ^[1].

Age rules differ by drug: at least 12 years for Qsymia, Saxenda, Wegovy injection and Xenical, and older than 16 for all other listed medications ^[1]. Treatment must be used alongside lifestyle changes such as dietary or caloric restriction, exercise, behavioral support or a community-based program ^[1].

On body weight, the policy requires a BMI of 30 or higher (or, for pediatric patients, a BMI at or above the 95th percentile), or a BMI of 27 or higher plus a weight-related condition such as dyslipidemia, high blood pressure, type 2 diabetes or sleep apnea ^[1]. There is a third path: no BMI requirement applies when Wegovy injection is requested for MASH ^[1].

First approvals are time-limited and vary by product. Benzphetamine, diethylpropion, phendimetrazine and phentermine get 3 months; Contrave, Qsymia and Saxenda get 4 months; Wegovy injection, Wegovy tablet and Wegovy HD get 5 months; Foundayo, Xenical and Zepbound get 6 months ^[1].

Renewals hinge on documented weight loss

To continue coverage, the policy requires documented weight loss from baseline plus continued lifestyle modification ^[1]. The thresholds differ: at least 3% for Qsymia, at least 4% for Saxenda, at least 5% for Wegovy injection, Wegovy tablet and Wegovy HD, and at least 5% for all other appetite suppressants — which covers Zepbound and Foundayo ^[1]. For Wegovy injection used for MASH, renewal instead requires documentation of a positive clinical response, such as improvement or stabilization of fibrosis, and that the patient has not progressed to cirrhosis ^[1].

Renewals run 12 months for Contrave, Foundayo, Qsymia, Saxenda, Wegovy injection or tablet, Wegovy HD, Xenical and Zepbound, and 6 months for benzphetamine, diethylpropion, phentermine and phendimetrazine ^[1].

North Dakota fully insured Essential Health Benefits plans for small group and individual coverage follow a stricter section. There, Wegovy injection, Wegovy HD or Zepbound require a BMI of 40 or higher (or, for children, at or above 120% of the 95th percentile), unless Wegovy injection is being requested for MASH ^[1].

Why it matters for patients

The practical effect is that coverage is not a one-time decision. Under this program, a first approval for Wegovy lasts 5 months and for Zepbound or Foundayo 6 months, after which the plan looks for at least 5% weight loss from baseline before granting a 12-month renewal ^[1]. That makes baseline and follow-up weights recorded in the medical record part of the coverage process.

The list also shows where newer products stand. A footnote says Foundayo and Wegovy tablet "may be in Exclude at Launch" — meaning these may not be covered initially even on plans that use this program ^[1]. The document also notes that supply limits may be in place, and that state mandates, federal rules, the member's specific benefit plan and other utilization management programs can all affect coverage ^[1].

What happens next

The policy's effective date is 9/1/2026 ^[1]. The change control log shows frequent updates — with prior effective dates in 2024, 2025 and 2026, including 2/2026, 4/2026 and 5/2026 — so further revisions are likely, though no future date is announced in the document ^[1]. How individual employers apply the program, and whether Foundayo and Wegovy tablet move off exclusion, is not stated in the source.