Is Wegovy Covered by Aetna?
Yes, but only under specific criteria.
Aetna may cover Wegovy (semaglutide) for weight loss when certain medical requirements are met. Coverage is plan-dependent and typically includes:
- BMI of 30 or greater, or BMI of 27 or greater with at least one comorbidity (e.g., type 2 diabetes, high blood pressure, or high cholesterol).
- Participation in a structured weight management program involving a reduced-calorie diet, physical activity, and behavior modification for at least 6 months.
- Evidence that lifestyle interventions alone were insufficient.
Does Wegovy Require Prior Authorization?
Yes.
Aetna requires prior authorization before covering Wegovy. Documentation must include:
- Current BMI and weight
- Comorbid conditions
- Proof of lifestyle intervention attempts
- Treatment plan and dosage
Are There Limits to Wegovy Coverage?
Yes.
Wegovy coverage is subject to limits, including:
- Quantity limits per month
- Initial authorization for 12 weeks, during which patients must demonstrate at least 5% weight loss at the maintenance dose to continue treatment
Can Pediatric Patients Get Coverage for Wegovy?
Possibly.
Wegovy is FDA-approved for adolescents aged 12–17 with obesity. Aetna may provide coverage for pediatric patients meeting the criteria, though this is plan-specific.
What Documentation Is Needed?
Your provider will need to submit:
- Current BMI and medical history
- Description of previous weight loss efforts
- Proposed dosage and duration of therapy
- Medical necessity statement
What If Coverage Is Denied?
You can appeal the decision with supporting medical documentation. If coverage is not available, patients may be eligible for manufacturer savings cards or discount programs.
Recent Policy Changes
As of 2025, Aetna continues to cover Wegovy for eligible patients but has removed Zepbound from its weight management drug list. This makes staying up to date with formularies especially important.
Where to Find More Information
Visit Aetna’s website or speak with customer service to confirm plan-specific coverage for Wegovy.