Does Aetna cover Wegovy? A comprehensive guide

Will Aetna cover your Wegovy prescription? We break down the coverage details and help you navigate the process.

Wegovy is a GLP-1 receptor agonist medication, FDA-approved for chronic weight management and cardiovascular risk reduction in patients with obesity and overweight.

The list price for Wegovy is $1,349.02 per package without insurance, according to the manufacturer, Novo Nordisk. The average retail price could range from $1,300 to $1,500 at local pharmacies. However, insurance coverage can make expensive medications like Wegovy accessible to patients.  For those without insurance, the high cost of the medication can be challenging.

Aetna, a private insurance company, may cover Wegovy under specific conditions if you are obese (BMI of 30 or more) or overweight (BMI of 27 or more).

This article provides a detailed overview of Aetna’s coverage policies for Wegovy, eligibility criteria, prior authorization requirements, and potential costs.

What is Wegovy?

Wegovy is a GLP-1 receptor agonist that contains semaglutide as an active ingredient. Semaglutide has 94% structural similarity to glucagon-like peptide-1. GLP-1 is a natural hormone produced by the body after food intake to give you a feeling of fullness or satiety.

• Semaglutide occupies GLP-1 receptors in the brain to suppress appetite and delay stomach emptying. The food stays in your stomach for a longer time, giving you feelings of fullness earlier and for a prolonged period.
• The medication promotes insulin release and reduces glucagon secretion from the liver, which lowers blood sugar levels.
• Additionally, Wegovy converts white adipose tissues into brown adipose tissues to prevent body disfigurement caused by obesity.

Wegovy is FDA-approved for promoting weight loss in adults with obesity (BMI 30 kg/m² or more) and overweight (BMI 27 kg/m² or more) with at least one health condition associated with increased body weight such as high blood pressure (hypertension), high cholesterol levels, heart diseases, and type 2 diabetes in patients aged 12 or more, when combined with exercise and dietary modifications.

Clinical studies show that a 2.4 mg once-weekly injection of Wegovy resulted in a 10-15% (or 10-15 kg) weight reduction after 68 weeks. In comparison, the placebo group lost only 2-3% of body weight on average.

On March 8, 2024, the FDA (U.S. Food and Drug Administration) approved Wegovy for cardiovascular risk reduction in patients with existing cardiovascular diseases, and overweight or obesity, as an adjunct to a reduced calorie diet and increased physical activity.

Wegovy costs about $1,300 to $1,400 per month without insurance, which may make the medication unaffordable for most patients without insurance coverage. However, private insurance companies like Aetna, Blue Shield Blue Cross, Cigna, and United Healthcare offer coverage for Wegovy under specific conditions, which may make the medication affordable.

Does Aetna cover Wegovy?

Yes, Aetna may cover Wegovy, but coverage depends on your specific Aetna plan, eligibility criteria, prior authorization requirements, and whether the medication is a medical necessity. Many Aetna plan benefit descriptions exclude obesity-related services and supplies. Aetna covers up to 26 individual or group weight loss counseling visits per year for adults with a BMI of 30 or higher if they meet eligibility criteria.

You should verify coverage with Aetna directly, as coverage varies by insurance plan.

Aetna’s coverage policies for Wegovy

Aetna may cover Wegovy for weight loss and cardiovascular risk reduction in adults who meet specific criteria. Wegovy must be used for the following FDA-approved indications to get Aetna coverage:

Use the medication along with a reduced-calorie diet and increased physical activity:

• To lower the risk of serious cardiovascular events (such as death from cardiovascular disease, non-fatal heart attack, or non-fatal stroke) in adults who have existing heart disease and are either overweight or obese.
• To support weight loss and help maintain long-term weight management in:
  • Adults and adolescents aged 12 years and older who have obesity, or;
  • Adults who are overweight and have at least one weight-related health issue

Usage limitations

Wegovy contains the active ingredient semaglutide. It should not be used together with other products that contain semaglutide or with other GLP-1 receptor agonists.

Eligibility criteria

Wegovy coverage for weight loss requires prior authorization and may be approved when you meet the following criteria:

For adults (18 years and older):

Continuation of therapy:

• The patient is 18 years of age or older, and;
• The patient has completed at least 3 months of Wegovy therapy at a stable maintenance dose, and;
• The patient has achieved at least a 5% reduction in baseline body weight or has maintained this 5% weight loss. Documentation of weight loss or maintenance is required for approval.

OR

New initiation of therapy for chronic weight management:

• The patient is 18 years of age or older, and;
• Wegovy will be used alongside a reduced-calorie diet and increased physical activity, and;
• The patient has participated in a comprehensive weight management program for at least 6 months that includes behavioral modification, dietary changes, physical activity, and ongoing follow-up, and;
• The patient has a body mass index (BMI) of ≥ 30 kg/m², or;
• The patient has a BMI of ≥ 27 kg/m² with at least one weight-related comorbid condition such as hypertension (high blood pressure), type 2 diabetes mellitus, or dyslipidemia (abnormal lipid levels in the blood).

For adolescents (ages 12 to 17):

Continuation of therapy:

• The patient is between 12 and 17 years of age, and;
• The patient is continuing treatment after successfully titrating to a stable maintenance dose, and;
• The patient has shown a reduction in BMI from baseline or has maintained the BMI reduction. Documentation is required for approval.

OR

New initiation of therapy for chronic weight management:

• The patient is between 12 and 17 years of age, and;
• The patient will use Wegovy alongside a reduced-calorie diet and increased physical activity, and;
• The patient has participated in a comprehensive weight management program for at least 6 months that includes behavioral modification, dietary changes, physical activity, and ongoing follow-ups, and;
• The patient has an initial BMI at or above the 95th percentile for age and sex (meeting criteria for obesity).

Exclusion criteria

Aetna does not cover Wegovy if taken for weight loss only.

Does Aetna cover Wegovy for heart disease?

Yes, Aetna may cover Wegovy for heart disease. It also requires prior authorization from a licensed healthcare professional. The patient should meet the following criteria to get Wegovy coverage for cardiovascular risk reduction:

Initial therapy:

• Wegovy is prescribed to reduce the risk of cardiovascular death, non-fatal heart attack, or non-fatal stroke in an adult with established cardiovascular disease who is also overweight or obese, and;
• Wegovy will be used in combination with a reduced-calorie diet and increased physical activity, and;
• The request is not for the continuation of therapy, and;
• The patient has established cardiovascular disease with a documented history of at least one of the following:
  A) Previous myocardial infarction (MI)
  B) Previous stroke
  C) Symptomatic peripheral arterial disease (PAD), evidenced by one of the following:
  – Intermittent claudication with an ankle-brachial index (ABI) less than 0.85 at rest
  – Peripheral arterial revascularization procedure
  – Amputation due to atherosclerotic disease
  D) Prior revascularization, such as coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or angioplasty, and;
• The patient has a baseline body mass index (BMI) of 27 kg/m² or higher, and;
• The patient does not have type 2 diabetes (patients with type 2 diabetes and cardiovascular disease should be considered for Ozempic, which is indicated for this use), and;
• The patient is either receiving guideline-directed medical therapy (GDMT) for cardiovascular disease or has a documented clinical reason for not receiving it (such as a contraindication to lipid-lowering agents, antiplatelets, beta-blockers, or renin-angiotensin inhibitors)
  (Documentation is required for approval)

Continuation of therapy:

• The request is for continued treatment, and;
• The patient has established cardiovascular disease with a documented history of at least one of the following:
  A) Previous myocardial infarction (MI)
  B) Previous stroke
  C) Symptomatic peripheral arterial disease (PAD), as outlined above
  D) Prior coronary revascularization (CABG, PCI, or angioplasty), and;
• The patient is currently receiving a maintenance dose of Wegovy.

The duration of approval for initial therapy and continuation therapy is 7 months and 12 months, respectively.

Is prior authorization required for Wegovy?

Yes, prior authorization is required for Wegovy insurance coverage with Aetna. You will need to contact your healthcare provider to help with this process. They will create a coverage request letter that can follow the recommendation in the Wegovy patient coverage request sample letter. You will submit the coverage request letter to your insurance provider to request coverage for Wegovy. Your insurance provider will typically respond within a few days and let you know if your request was approved or denied.

How to check if your Aetna plan covers Wegovy

You can check Aetna’s prescription drug coverage for Wegovy by following these steps:

• Contact Aetna customer service. You can call the member service number provided on your insurance card for personalized guidance.
• You can log into the Aetna member website and contact the help centre through live chat, phone, or email.
• Use Aetna’s online portal or mobile app to check the drug formulary (list of covered drugs).
• You can also use Novo Nordisk’s online tool to check your Aetna plan’s coverage for Wegovy.

Aetna’s formulary and Wegovy

A drug formulary is a list of medications covered by an insurance plan.

You can find Aetna’s formulary online and check if Wegovy is listed. You can see a list of all drugs covered by your plan, drug tiers, eligibility requirements, prior authorization requirements, and limitations. Medications on lower tiers will have lower out-of-pocket costs.

Follow the steps below to view the complete list of covered drugs in your insurance plan.

• Go to Aetna’s website and select find a medication.
• Enter your plan year and name.
• If you are enrolled in a Medicare Advantage plan (which includes both medical and prescription coverage), you can find your plan name on your member ID card.
• If you have a stand-alone prescription drug plan (PDP), check the “S” number located in the bottom right corner of your ID card. Then, select the plan from the drop-down menu that matches this “S” number.
• Download the list, and check out all relevant details related to Wegovy’s coverage.

Cost of Wegovy with Aetna coverage

The cost of Wegovy with Aetna coverage may vary depending on your specific Aetna insurance plan, yearly deductibles, and individual circumstances. You can use Aetna’s online cost estimator tool to check your out-of-pocket costs or contact your insurance provider by calling the phone number on the back of your insurance card.

What can I do if Aetna doesn’t cover Wegovy?

If Aetna does not cover Wegovy, you can follow these tips to reduce its cost:

• File an appeal for Wegovy coverage if your request has been denied as soon as possible as there is limited time for requesting an appeal.
• Review all insurance documents, clarify queries from the insurer, follow the appeal process and submit your claim as soon as possible by the due date.
• Consult with your state’s insurance commissioner for guidance if needed.
• You can contact Aetna customer support in case of any questions.
• If you are still unable to obtain insurance coverage for Wegovy, try exploring other ways to save on Wegovy as explained below.

How to save on Wegovy

You can save on Wegovy with the help of saving card programs, pharmacy discount cards, coupons, and by switching to compounded semaglutide.

Wegovy Savings Card

Novo Nordisk, the company that makes Wegovy, offers a Wegovy Savings Card to help reduce the cost of the medication. If you have commercial insurance that covers Wegovy, you may be eligible to receive your monthly supply of Wegovy at no cost ($0) using the savings card.

If your insurance does not cover Wegovy, or if you don’t have insurance, you may still be able to get a monthly supply of Wegovy for $499. You cannot be enrolled in any government-sponsored health insurance such as Medicare, Medicaid, VA Benefits, or Tricare.

Wegovy coupons and discount cards

Pharmacy discount cards provided by websites like GoodRx, SingleCare, BuzzRx, and WellRx offer prescription coupons that can help lower out-of-pocket costs for prescription medications including Wegovy. These websites allow you to compare prices at different pharmacies and access digital or printable coupons directly from their websites or mobile apps. Depending on the pharmacy and location, these discounts can reduce the cash price of Wegovy by 9% to 27%.

Compounded semaglutide

Compounded semaglutide is a customized form of the drug semaglutide prepared by compounding pharmacies to meet the unique needs of patients. It contains the same active ingredient (semaglutide) as Wegovy, but is not reviewed by the FDA for safety or effectiveness. However, it offers a more affordable option for patients who can not access brand-name drugs and is easily accessible during drug shortages. It typically costs between $200 and $300 for a monthly supply.

NovoCare Pharmacy

You can pay $499 per month for Wegovy when purchasing through NovoCare Pharmacy, the direct-to-consumer website of the manufacturer, Novo Nordisk.

Alternatives if Aetna doesn’t cover Wegovy

If Aetna does not cover Wegovy, you can try these alternative options:

• Aetna covers other GLP-1 medications such as Saxenda (liraglutide) and Zepbound (tirzepatide), if you meet their eligibility criteria. You can discuss these weight loss medications with your healthcare provider.
• You can use the Wegovy Savings Card without insurance or buy Wegovy through NovoCare Pharmacy for $499 per month.
• You can also make lifestyle changes such as dietary modification, regular exercise, and increased physical activity which help reduce weight.
• Other weight loss medications such as Qsymia (phentermine/topiramate), Contrave (naltrexone/bupropion), and Xenical (orlistat) can also be used as an alternative to Wegovy.
• Aetna may cover weight loss (bariatric) surgery when specific medical necessity criteria are met. Coverage depends on the member’s plan. Some Aetna HMO and QPOS plans require prior approval, while others may exclude bariatric surgery entirely. It’s important to review your specific benefit plan details to confirm coverage.

Tips for maximizing Aetna coverage for Wegovy

Here are a few practical tips for maximizing insurance benefits and minimizing out-of-pocket costs when using Wegovy:

• Work closely with your healthcare provider to meet eligibility criteria. Get a coverage request letter from your doctor and submit it to your insurance company.
• In case of any questions, contact Aetna’s customer support or login to your Aetna member website to get support through chat, phone or email.
• If Aetna denies your request, request an appeal by the due date. Check all relevant documents and make sure to send an effective appeal letter with the help of your doctor.
• You can also contact your state’s insurance commissioner for further guidance if needed.

Frequently asked questions

Does Aetna cover Wegovy for weight loss?

Yes, Aetna may cover Wegovy for weight loss but it depends on your insurance plan and prior authorization requirements. Some Aetna plans exclude weight loss medications from coverage, while others cover the medication under certain conditions. It is better to verify with your Aetna plan provider whether your plan covers Wegovy.

What is the cost of Wegovy with Aetna insurance?

The cost of Wegovy with Aetna insurance may vary depending on your insurance plan, yearly deductible, and copays. You can use Aetna’s online cost estimator and medicine search tool to check how much the medication will cost with insurance.

How do I get prior authorization for Wegovy with Aetna?

You can get prior authorization for Wegovy with the help of your licensed healthcare provider. They should provide you with a coverage request letter (you can provide them with the example Wegovy patient coverage request letter) detailing your health condition and other relevant details. You can submit this letter to Aetna with any other documents required for the prior authorization.

Does Aetna Medicare cover Wegovy?

Generally, Medicare does not cover Wegovy as weight loss medications are not considered a “medical necessity”. However, it may be covered by Medicare Part D when used for medically accepted indications (e.g. cardiovascular risk reduction).

What if my Aetna plan denies coverage for Wegovy?

If your Aetna plan denies coverage for Wegovy, you can request an appeal by the due date. If your insurance provider does not approve the request, you can consider using the Wegovy savings card or pharmacy discount coupons. You can also try alternatives to Wegovy such as compounded semaglutide, other GLP-1 medications such as liraglutide and tirzepatide, or non-GLP-1 medications such as Qsymia, Orlistat, and Contrave. Exercise and lifestyle modifications can also be helpful in weight reduction.

Bottom line

Aetna may cover Wegovy, but coverage varies by insurance plan and requires meeting specific criteria. There are different eligibility criteria for Wegovy when used for weight loss and cardiovascular risk reduction. However, some Aetna plans exclude weight loss medications from the coverage list.

Contact your insurance provider to verify if your plan covers Wegovy. You can also use the Aetna medication search tool to find more information.

If you can’t get Aetna coverage for Wegovy, you can try alternative options such as Wegovy Saving Card, pharmacy coupons from GoodRx and SingleCare, and compounded semaglutide. Seek medical advice and discuss your insurance benefits with your healthcare provider so they can recommend the most suitable plan for you.

Contact Aetna to confirm your Wegovy coverage and take the next step toward your weight management goals.

Trusted source

U.S. Food and Drug Administration

• Federal regulatory agency for food and health-related products

Go to source

Trusted source

U.S. Food and Drug Administration

• Federal regulatory agency for food and health-related products

Go to source