Is Zepbound Covered By Aetna?
Yes, but only under specific conditions.
Zepbound (tirzepatide) is FDA-approved specifically for chronic weight management in adults with obesity or overweight individuals who also have at least one weight-related condition. Aetna may cover Zepbound when medical necessity is demonstrated and plan criteria are met.
Does Zepbound Require Prior Authorization?
Yes.
Aetna typically requires prior authorization for Zepbound coverage. Submissions should include:
- Current BMI (≥30 or ≥27 with comorbidity)
- Comorbid conditions (e.g., hypertension, diabetes)
- History of lifestyle intervention
- Proposed dosage and treatment plan
Are There Coverage Restrictions?
Yes.
Zepbound coverage may include:
- Quantity limits (e.g., one injection pen per week)
- Initial authorization period (e.g., 12 weeks)
- Demonstrated weight loss (e.g., ≥5%) for continued approval
Is Zepbound Covered for Adolescents?
Not at this time.
Zepbound is currently only FDA-approved for adults. Pediatric coverage would require off-label approval, which is unlikely through most Aetna plans.
What Documentation Is Needed?
For best approval chances, your provider should submit:
- BMI and full medical history
- History of previous weight loss attempts and interventions
- Comorbid condition details
- Justification for using Zepbound
What If Coverage Is Denied?
An appeal may be submitted with:
- A letter of medical necessity
- Progress notes and supporting clinical data
- Alternative options tried and failed
Recent Policy Notes
As of 2025, Zepbound has been excluded from several Aetna formularies in favor of alternatives like Wegovy. Patients should verify their plan’s latest drug list.
Where to Get More Info
Related pages: Ozempic, Mounjaro, Saxenda, Qsymia, Contrave
FAQ: Aetna and Zepbound Coverage
Is Zepbound covered by Aetna?
Possibly. Some Aetna plans are starting to include Zepbound for patients who meet prior authorization and medical criteria.
Does Zepbound require a prior authorization with Aetna?
Yes. Prior authorization is required for nearly all Aetna plans.
How can I increase my chance of approval?
Have your doctor document BMI, past failed weight loss methods, comorbidities, and include a strong medical necessity letter.
Is Zepbound covered for diabetes too?
No. Zepbound is approved for weight loss. Mounjaro (tirzepatide) is approved for type 2 diabetes.
Can I use a savings card with Aetna insurance?
Yes, especially if you have commercial insurance. Use the official Zepbound savings program for support.
Medical Disclaimer
This page is for informational purposes only and does not constitute medical advice. Coverage for Zepbound varies by Aetna plan and geographic region. Always consult your doctor and your health plan before starting any prescription treatment.