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UnitedHealthcare appeal guide

UnitedHealthcare Wegovy coverage appeal

UnitedHealthcare uses specific clinical-policy criteria for Wegovy. Most denials come from undocumented BMI history or missing step-therapy notes. Here is how to address both.

UnitedHealthcare prior authorization criteria for Wegovy

  • BMI ≥30 (or ≥27 + at least 2 comorbidities)
  • 6-month lifestyle intervention
  • Step therapy with at least one anti-obesity medication
UnitedHealthcare Wegovy policy bulletin

Step-by-step appeal flow

  1. 1

    Pull your carrier policy bulletin

    UnitedHealthcare publishes its Wegovy coverage criteria. Read it first — every successful appeal cites it back to the reviewer.

  2. 2

    Document your medical necessity

    BMI ≥30 (or ≥27 + at least 2 comorbidities) 6-month lifestyle intervention Step therapy with at least one anti-obesity medication

  3. 3

    Have your prescriber submit the PA

    Most UnitedHealthcare PAs go through CoverMyMeds or the carrier portal. Your prescriber attaches BMI history, comorbidities (with ICD-10 codes), lifestyle program participation, and prior weight-loss attempts.

  4. 4

    If denied — file the appeal within 60 days

    UnitedHealthcare requires comorbidity count — list every applicable diagnosis. Reference the specific UHC policy document by drug name.

  5. 5

    Submit external review if internal appeals fail

    After two internal appeals, you can request external review through your state insurance commissioner. ERISA plans go through the federal external-review process.

Letter template

Customizable UnitedHealthcare appeal letter

We provide a generic medical-necessity letter generator. Customize with the UnitedHealthcare-specific framing above for highest first-pass success.

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People also ask

Common questions readers ask

How much does Wegovy cost without insurance?
List price runs ~$1,350/mo at retail. NovoCare Pharmacy cash-pay direct from Novo Nordisk is $499/mo for all dose strengths. The Wegovy Savings Offer caps copay at $0-$225/mo for commercially insured patients depending on coverage status (not a flat $225 for everyone).
Full evidence-graded answer
Is Ozempic the same as Wegovy?
Same active molecule (semaglutide), different FDA indications and maximum doses. Ozempic = type 2 diabetes, max 2 mg/week. Wegovy = chronic weight management, max 2.4 mg/week. Insurance pathways are very different.
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Can I still get compounded GLP-1 in 2026?
For semaglutide: no — FDA declared the shortage resolved February 21, 2025 and 503A compounding is no longer broadly permitted. For tirzepatide: shortage resolved October 2024 (re-affirmed December 2024), with a wind-down enforcement window that ended in 2025. Some clinics still market "compounded" formulations with added ingredients (B12, glycine) as personalized prescriptions; the legal status is contested.
Full evidence-graded answer
How does Wegovy compare to Saxenda?
Both are GLP-1 agonists from Novo Nordisk. Wegovy (semaglutide, weekly) produces ~15% mean weight loss; Saxenda (liraglutide, daily) produces ~6-8%. Wegovy is also cheaper per kg-lost, more convenient, and has cardiovascular outcome data (SELECT trial). Saxenda was first approved for adolescents (2020); Wegovy followed in 2022 — both are available for ages 12-17.
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Editorial information based on published UnitedHealthcare coverage policies as of 2026. Your specific plan benefits may differ — confirm with your insurance card’s member services number. Not legal advice.