Wegovy is a popular medication for weight loss, helping many achieve significant results. With its growing use, people often ask, “Does Aetna cover Wegovy for weight loss?”
Coverage depends on your specific Aetna plan and medical criteria. This article explores Aetna’s policies, eligibility requirements, and steps to secure coverage.
Understanding your insurance options can save money and simplify treatment. Read on to learn about Wegovy, Aetna’s coverage, and tips for managing costs.
What Is Wegovy?
Wegovy is a prescription drug with the active ingredient semaglutide. It’s a GLP-1 receptor agonist that reduces appetite and promotes weight loss. Approved by the FDA for chronic weight management, it’s used for adults with obesity or overweight with related health conditions.
Administered as a weekly injection, Wegovy is most effective with a reduced-calorie diet and exercise. Clinical trials show users lose up to 15–20% of body weight on average.
Related: Does UnitedHealthcare Cover Wegovy for Weight Loss
How Wegovy Works for Weight Loss
Wegovy mimics a hormone that regulates hunger and blood sugar. It slows digestion, helping you feel full longer and reducing cravings. This leads to lower calorie intake and sustained weight loss.
It also improves blood sugar control, benefiting those with type 2 diabetes. Its mechanism supports long-term weight management when combined with lifestyle changes.
Does Aetna Cover Wegovy for Weight Loss?
Does Aetna cover Wegovy for weight loss? Many Aetna plans cover Wegovy as a preferred brand drug, but coverage varies by plan. Most require prior authorization and specific criteria, like a BMI of 30 or higher. Some plans exclude weight loss medications, so checking your policy is essential.
Recent changes, effective July 1, 2025, favor Wegovy over other GLP-1 drugs like Zepbound in some plans. This makes coverage more likely for eligible members.
Aetna’s Coverage Criteria
To qualify for Wegovy coverage, Aetna typically requires:
- A BMI of 30 kg/m² or higher (obesity) or 27 kg/m² with conditions like hypertension or diabetes.
- Documented weight management efforts for at least six months, including diet and exercise.
- Prior authorization with clinical evidence from your doctor.
These criteria ensure Wegovy is medically necessary. Check your plan’s formulary for specifics.
Recent Policy Updates
Starting July 1, 2025, some Aetna plans, particularly those managed by CVS Caremark, prioritize Wegovy for weight loss coverage. This shift is due to negotiated pricing with Novo Nordisk, Wegovy’s manufacturer. Other GLP-1 drugs, like Zepbound, may be excluded in favor of Wegovy.
If your plan excludes Wegovy, your doctor can request a medical exception. This requires proof of Wegovy’s necessity over alternatives.
Table: Aetna Coverage for Common Weight Loss Medications
| Medication | Coverage Status | Prior Authorization Required? | Notes |
|---|---|---|---|
| Wegovy | Covered by many plans | Yes | Preferred for weight loss; high copay possible. |
| Zepbound | Excluded in some plans after July 1, 2025 | Yes | Alternative GLP-1; coverage varies. |
| Saxenda | Covered by some plans | Yes | Less effective for some; higher tier. |
| Orlistat | Covered by some plans | Sometimes | Lower-cost option; less potent. |
Why Coverage Varies
Aetna offers various plans with different formularies and exclusions. Some plans exclude weight loss drugs due to cost or employer preferences. Others cover Wegovy only for specific conditions, like obesity with comorbidities.
Log in to your Aetna member portal or call Member Services to confirm coverage. This clarifies copays, deductibles, and authorization requirements.
The Prior Authorization Process
Most Aetna plans require prior authorization for Wegovy. Your doctor submits a form with your BMI, medical history, and proof of prior weight loss attempts. This demonstrates Wegovy’s medical necessity.
The process may take days to weeks. Complete documentation, like diet or exercise logs, can speed up approval.
What If Aetna Denies Coverage?
If Aetna denies Wegovy coverage, you can appeal the decision. Your doctor can provide additional evidence, like Wegovy’s effectiveness for your condition. Appeals may take time, so act quickly.
Explore covered alternatives like Saxenda or Orlistat if Wegovy isn’t approved. Your doctor can recommend the best option.
Cost of Wegovy Without Insurance
Without insurance, Wegovy costs around $1,300–$1,500 per month. This high price makes coverage critical for most users. If Aetna doesn’t cover Wegovy, the Wegovy Savings Card can lower costs to as little as $0 for eligible commercially insured patients with coverage.
For those without coverage, the card caps costs at $500 monthly for up to 24 months. Check eligibility with Novo Nordisk.
Alternatives to Wegovy
If Wegovy isn’t covered, Aetna may cover other weight loss drugs like Saxenda, Orlistat, or phentermine. Saxenda, another GLP-1 agonist, is effective but may have higher copays. Orlistat is a lower-cost option but less potent for many.
Lifestyle changes, like diet and exercise, are also effective. Discuss options with your doctor to find a covered solution.
Tips for Getting Wegovy Covered
- Check your plan’s formulary on Aetna’s website to confirm Wegovy’s status.
- Work with your doctor to submit a detailed prior authorization request.
- Document six months of diet and exercise efforts to meet criteria.
- Appeal denials with additional medical evidence if needed.
These steps improve your chances of approval and reduce costs.
Lifestyle Changes to Support Wegovy
Wegovy works best with a reduced-calorie diet and increased physical activity. Eat nutrient-dense foods like vegetables, lean proteins, and whole grains. Aim for 150 minutes of moderate exercise weekly, like brisk walking or cycling.
Behavioral changes, like portion control and stress management, enhance results. Aetna’s CVS Weight Management program offers personalized support.
When to Contact Your Doctor
Contact your doctor if you experience severe side effects like nausea, vomiting, or abdominal pain. These could indicate issues like pancreatitis. If Wegovy isn’t covered, your doctor can assist with appeals or suggest alternatives.
Regular check-ups monitor your progress and adjust your treatment. This ensures safe and effective use of Wegovy.
Exploring Other Cost-Saving Options
If Aetna doesn’t cover Wegovy, the Wegovy Savings Card can significantly reduce costs for eligible patients. Check with Novo Nordisk for eligibility and application details. Compare pharmacy prices, as costs vary by location.
Ask about 90-day prescriptions to save on refills. Novo Nordisk’s patient assistance programs may help uninsured patients.
Summary
Does Aetna cover Wegovy for weight loss? Many Aetna plans cover Wegovy as a preferred drug, especially after July 1, 2025, when it’s prioritized over alternatives like Zepbound. Coverage requires prior authorization and a BMI of 30 or higher (or 27 with comorbidities). Some plans may exclude weight loss drugs, so check your formulary.
If coverage is denied, appeal or use the Wegovy Savings Card to lower costs. Pair Wegovy with diet, exercise, and Aetna’s support programs for best results. Work with your doctor to navigate authorization and ensure safe, affordable treatment.
FAQ
Does Aetna cover Wegovy for weight loss?
Many Aetna plans cover Wegovy, especially after July 1, 2025, but require prior authorization. You need a BMI ≥30 or ≥27 with conditions like diabetes. Check your plan’s formulary for details.
What are Aetna’s criteria for Wegovy coverage?
You need a BMI of 30 or higher (or 27 with comorbidities) and six months of documented diet/exercise efforts. Prior authorization is required. Confirm specifics with your plan’s formulary.
What if my Aetna plan doesn’t cover Wegovy?
Appeal the denial with your doctor’s help or explore covered alternatives like Saxenda. The Wegovy Savings Card can reduce costs to $0–$500 monthly. Check eligibility with Novo Nordisk.
How much does Wegovy cost without insurance?
Wegovy costs $1,300–$1,500 monthly without insurance. The Wegovy Savings Card can lower costs to $0 for covered patients or $500 for uncovered ones. Compare pharmacy prices for savings.
What should I do if I experience side effects on Wegovy?
Report severe nausea, vomiting, or abdominal pain to your doctor immediately. These may indicate serious issues like pancreatitis. Regular check-ups ensure safe use and address concerns.