Does OptumRx cover Wegovy?

If OptumRx manages your prescription drug benefits, you might be wondering whether GLP-1s like Wegovy (semaglutide) are covered. So, does OptumRx cover Wegovy? It depends on your plan. Wegovy is a covered medication on some plans, and sometimes it’s only covered for one condition, like cardiovascular risk reduction, but not another, like weight loss.

Read on as we explain.

It depends on the plan. Some OptumRx plans cover Wegovy as a mid-range Tier 2 drug (i.e. more expensive than a generic, but less expensive than a Tier 3 drug) with prior authorization. Other plans explicitly exclude Wegovy from coverage. 

OptumRx varies in its Wegovy coverage, largely due to its partnership with UnitedHealthcare (UHC). OptumRx is the pharmacy service provider for UHC. It maintains the drug formularies (lists of covered drugs), but employers can choose which drugs to cover when they design their plan benefits. 

UHC plan administrators may also opt in to cover certain categories of drugs, including GLP-1s like Wegovy. When this happens, it may cause a discrepancy between what you see in your plan documents and what OptumRx says is covered. In this scenario, what your UHC plan says goes.

See if you qualify

Does OptumRx cover Wegovy for weight loss?

Whether OptumRx covers Wegovy for weight loss also depends on your specific plan.

Some plans cover Wegovy as a Tier 2 Preferred Drug for weight loss with prior authorization. Other OptumRx plans don’t cover the Wegovy pill or injection at all. 

When OptumRx covers Wegovy for weight loss, you’ll need to meet certain clinical criteria for obesity or overweight, based on your body mass index (BMI). (Not sure of your BMI? Our free BMI calculator can help you figure it out.)

If your Part D prescription drug benefits are managed through OptumRx, Medicare covers Wegovy for weight loss through the GLP-1 Bridge program. Your healthcare provider may need to submit prior authorization before coverage is approved.

Does OptumRx cover Wegovy for cardiovascular risk reduction?

Same answer here: Whether OptumRx covers Wegovy for cardiovascular risk reduction varies by plan. 

When OptumRx does cover Wegovy, it’s generally as a Tier 2 Preferred Drug and prior authorization is required. To qualify for coverage, you’ll need to have a diagnosis of heart disease and a BMI of 27 or higher.

Does OptumRx cover Wegovy for fatty liver disease?

And one more time for the folks in the back: It depends on your plan. 

If your OptumRx plan covers Wegovy for fatty liver disease, it may be categorized as a Tier 2 Preferred Drug and require prior authorization. Not all OptumRx plans cover Wegovy. To qualify for coverage, you need to have fatty liver disease with moderate to advanced liver fibrosis (i.e. stage F2 or F3) and a BMI of 27 or higher.

Yes, OptumRx usually requires prior authorization for Wegovy. This means your healthcare provider will need to send in paperwork to OptumRx to get Wegovy approved for coverage. Prior authorization will only be approved if you meet all four of the following criteria: 

1. You must be taking Wegovy for one of the following FDA-approved indications:

• Weight loss (Wegovy injection and pill)

• Cardiovascular risk reduction (Wegovy injection and pill)

• Fatty liver disease (Wegovy injection)

2. You must be a certain age, depending on the drug form and purpose of prescription: 

• At least 12 years old (if you’re taking the Wegovy injection for obesity) 

• At least 18 years old (if you’re taking the Wegovy injection or pill for anything else)

3. You meet one of the following BMI requirements:

• BMI of 30 or higher

• BMI of 27 or higher, plus a weight-related health condition (e.g. high cholesterol, high blood pressure, sleep apnea, type 2 diabetes)

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4. You must plan to use Wegovy in combination with lifestyle changes, such as:

• Diet

• Exercise

• Behavioral support (some OptumRx plans will only approve Wegovy if you’re enrolled in a specific weight loss program)

• Community-based weight loss program, such as one through your local YMCA or senior center 

Here’s how to check if OptumRx covers Wegovy:

1. Call OptumRx directly. Call the customer service number on the back of your member ID card to ask if Wegovy is covered by your plan and, if so, your expected cost.

2. Use the OptumRx mobile app. Once you’re logged in, you can view your prescription drug benefits and expected pricing for Wegovy.

3. Log in to the OptumRx website. You can visit this link or go to the one listed on your ID card to sign in, look up Wegovy, and see your coverage details.

4. Use Ro’s free GLP-1 insurance coverage checker. Answer a few quick questions, and Ro will reach out to OptumRx for you. Then, they’ll email you a personalized report outlining your coverage details for Wegovy and other GLP-1 injections.

Without insurance, Wegovy can cost anywhere from $149 to upwards of $1,300, depending on form (pen vs. pill) and where you get your medication. 

On Ro, for example, you can get Wegovy at the following cash-pay prices (if prescribed):

• Wegovy pill: $149–$299 per month, depending on dose 

• Wegovy injection: $199–$399 per month, depending on dose 

With insurance (which you can also use on Ro, BTW), Wegovy can cost even less. If you’re eligible for the manufacturer savings card, for example, you may be able to get either form of the drug for just $25. And with the Medicare Part D GLP-1 Bridge program, Wegovy has a $50 monthly copay.

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Getting insurance to cover GLP-1s can be a process. OptumRx is no different. Here’s what to remember about OptumRx and getting coverage for Wegovy: 

• Coverage varies by plan. Some OptumRx plans don’t cover Wegovy at all, while others cover it as a Preferred Drug with prior authorization, or it may be excluded from coverage entirely.

• To get prior authorization for Wegovy on OptumRx, you must be taking it for an FDA-approved condition (i.e. weight loss, fatty liver disease, heart disease) and meet certain age and BMI requirements.

• You can check if OptumRx covers Wegovy by calling the number on your ID card, logging into the website or mobile app, or using Ro’s GLP-1 insurance checker.

• Without insurance, Wegovy can cost $1,349.02 at the pharmacy, but you can get it for lower self-pay prices of $149–$399*, depending on dose and form, on Ro (if eligible).

*Prices may reflect limited-time offers and are subject to change; see more here.