Does Aetna Cover Wegovy for Weight Loss? | Ro (2024)

If you’ve been prescribed Wegovy (semaglutide) and you have insurance through Aetna, you’re probably wondering if your plan includes coverage for Wegovy.

Does Aetna cover Wegovy? How much will you have to pay for Wegovy at the pharmacy? And if your plan doesn’t cover Wegovy, what are your options? Read on as we answer these questions and more.

Aetna’s coverage for Wegovy can vary depending on your specific plan. Some plans cover Wegovy, while others specifically exclude coverage for weight loss treatment. When Wegovy is covered by select Aetna plans, it may be considered a “preferred brand drug,” which usually comes with a slightly higher copay than generic drugs. Also, prior authorization is usually required.

Yes, Aetna typically requires prior authorization for Wegovy. The specific process for prior authorization can vary by insurance plan, but it generally involves your healthcare provider submitting a form demonstrating that Wegovy is a medically necessary treatment option for you.

When Aetna plans do cover Wegovy, they usually require prior authorization that shows you’ve met certain coverage criteria. These criteria differ depending on whether the prescription is for an adult or a child.

For adults ages 18 and older, you may qualify for coverage with a prior authorization by meeting either of the two conditions below:

1. You have already used Wegovy for at least three months at a stable maintenance dose and lost at least 5% of your baseline body weight (or maintained a 5% weight loss).

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2. You plan to use Wegovy in combination with diet and exercise, and you have already participated in a weight management program for at least six months prior to using medication. Moreover, you must have a body mass index (BMI) of either 30 or greater (defined as “obesity”); or 27 or higher (defined as “overweight”) and a weight-related health condition (such as high blood pressure, high cholesterol, or type 2 diabetes).

Children ages 12 to 17 years old could qualify for coverage with a prior authorization by meeting either of the two conditions below:

1. They have used Wegovy at a stable maintenance dose and have experienced (or maintained) some weight loss.

2. They plan to use Wegovy in combination with diet and exercise, and they have already participated in a weight management program for at least six months prior to using medication. Moreover, they must have a BMI that’s at or above the 95th percentile for their age and sex.

It’s possible that Aetna could cover Wegovy for weight loss if you have heart disease. In March 2024, the Food and Drug Administration (FDA) approved Wegovy for another purpose: to reduce the risk of cardiovascular death, heart attack, or stroke in adults with existing heart disease and either obesity or overweight. Select Aetna plans, such as the Advanced Control Plan, started covering Wegovy as of April 1, 2024.

To check if your Aetna plan covers Wegovy, call the Member Services number on the back of your insurance card. You can also contact Aetna through their website using phone, email, or chat. When you contact Aetna, here’s a list of questions you may want to ask to fully understand your coverage and out-of-pocket costs for Wegovy:

• Does my Aetna plan cover Wegovy?

• Do I need to do anything specific to get coverage, such as prior authorization?

• What is my expected copay for Wegovy?

• Do I need to meet a deductible or out-of-pocket requirement before my copay kicks in? If so, how close am I to meeting those for the year?

• Do I need to use a specific pharmacy to fill my prescription?

• Is there anything else I can do to get the best price, such as using a mail-order pharmacy or getting a longer, 90-day prescription?

• If my plan does not offer coverage, can I submit an appeal? What’s involved in that process? What else can I do to get coverage?

Novo Nordisk, the maker of Wegovy, offers a printable form on its website that includes these questions. The form includes space to write down your answers during your call with Aetna.

Novo Nordisk also offers an online tool called NovoCare that you can use to check insurance coverage for Wegovy. But, they may not always have the most up-to-date details on your coverage, so the best way is to go directly through Aetna.

You can also review your plan’s drug formulary. This is a list of the drugs covered by your plan. To see your formulary, visit the Aetna website here. Then, select the year under the “Choose a plan year” drop down menu, and select your plan under the “Choose a plan” drop down menu. Those who have a Medicare Prescription Drug Plan through Aetna can visit this website instead.

If Aetna denies your prior authorization, your healthcare provider can submit an appeal. Novo Nordisk offers a sample letter they can use. Have your healthcare provider print it out on their letterhead, and then bring the letter to your HR benefits manager at work–that person may be able to contact your insurance plan on your behalf.

Sometimes insurance plans won’t cover Wegovy, but they will cover cheaper weight loss medications. If your Aetna plan doesn’t cover Wegovy, you may want to ask your healthcare provider about alternatives to Wegovy. One such option may be compounded semaglutide. Though not approved by the FDA, compounded medications are allowed under federal law for various reasons, including during medication shortages. Companies such as Ro offer compounded semaglutide if you qualify.

Without insurance coverage, Wegovy costs $1,349.02 for a 28-day supply. But, there are ways you can save on the cost of Wegovy, even if Aetna won’t cover it. For example:

• People with commercial insurance plans, including Aetna, may be eligible for the Wegovy Savings Offer. With insurance coverage, it can help you get Wegovy for free. Without coverage, it brings the cost of Wegovy down to $650. The savings card can be used for up to 13 refills. People with government-funded insurance, including Medicare, Medicaid, and other state or federal plans, are not eligible.

• Several websites, such as SingleCare, Optum Perks, and GoodRx, offer prescription discount cards for various pharmacies.

• If you have a Flexible Savings Account (FSA) or Health Savings Account (HSA), you may be able to apply those funds toward the cost of refilling your prescription.

For help getting insurance coverage for Wegovy, talk to your benefits administrator.

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Every article on Health Guide goes through rigorous fact-checking by our team of medical reviewers. Our reviewers are trained medical professionals who ensure each article contains the most up-to-date information, and that medical details have been correctly interpreted by the writer.

Current version

August 06, 2024

Written by

Amelia Willson

Fact checked by

Patricia Weiser, PharmD

About the medical reviewer

Patricia Weiser, PharmD

Patricia Weiser, PharmD, is a licensed pharmacist, health content writer, and medical reviewer with more than a decade of clinical experience in community and hospital pharmacy.