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Wondering if your Aetna insurance plan covers Wegovy? This guide breaks down everything you need to know, including eligibility criteria, prior authorization, reasons for denial, and cost-saving options.
If you’re looking to get started with Wegovy, Klarity Health can help you connect with a licensed provider for support and documentation.
Does Aetna cover Wegovy?
Fortunately, many Aetna plans do cover Wegovy (semaglutide), but coverage depends on whether you meet medical criteria and typically requires prior authorization. Approval depends on your specific plan, employer, and state regulations. Some plans may exclude weight-loss medications entirely.
Not sure if your insurance covers Wegovy?
Klarity connects you with licensed providers who can evaluate your needs and determine if Wegovy is medically appropriate—coverage may vary by plan.
Eligibility criteria for Aetna coverage for Wegovy
Aetna requires members to meet specific clinical criteria before covering Wegovy. For adults, you must have a body mass index (BMI) of 30 or greater or a BMI of 27 or greater with at least one weight-related condition (like, hypertension, type 2 diabetes, dyslipidemia). You must demonstrate that you’ve completed a structured weight-management program (including diet, exercise, and behavioral support) for at least 6 months prior to starting Wegovy.
After 3 months on a stable maintenance dose of Wegovy, patients must demonstrate at least 5% weight loss to remain eligible.
Aetna will also usually cover Wegovy to reduce the risk of major adverse cardiovascular events (like heart attack, stroke, cardiovascular death), an FDA-approved use. Adults usually have to show a diagnosis of cardiovascular disease, have a BMI of 27 or greater, demonstrate participation in an active lifestyle program, and have no history of type 2 diabetes.
Adolescents (12–17)
- BMI at or above the 95th percentile for age and sex
- Must complete dose escalation and begin maintenance dosing
- Aetna requires documented BMI reduction or maintenance during treatment
How to know whether my Aetna covers Wegovy?
Checking your coverage is simple and quick, either online or by contacting Aetna directly.
1. Use Your Aetna Member Portal
- Log in to your account
- Go to the “Find a Medication” or “Drug Search Tool” section
- Search for “Wegovy” to view coverage status, tier, and authorization requirements
2. Call Aetna Member Services
Use the number on your insurance card and ask:
- Is Wegovy covered under my plan?
- Does it require prior authorization?
- What is my copay or coinsurance?
- Are there preferred pharmacies or mail-order options?
- If it’s not covered, is a medical exception possible?
3. Review Your Plan’s Formulary
Download your plan’s formulary, or list of covered drugs, and search for “Wegovy” or “semaglutide.” This document will tell you:
- If Wegovy is included
- Whether it’s on a preferred tier
- Whether prior authorization, step therapy, or quantity limits apply
4. Use NovoCare’s Online Coverage Tool
Novo Nordisk’s website offers a “Check Cost & Coverage” tool to estimate your insurance benefits. However, always verify directly with Aetna to confirm accuracy.
5. Confirm Prior Authorization Requirements
Most Aetna plans require:
- A BMI ≥ 30, or ≥ 27 with a comorbidity
- At least 6 months of prior weight-loss program participation
- Evidence of 5% weight loss after 3 months on the maintenance dose
Does Aetna cover Wegovy prescriptions online?
Did you know you may not even need an in-person provider visit to get coverage for Wegovy? Aetna supports electronic prior authorization submissions from healthcare providers, both online and in person. Wegovy can also be prescribed online through telehealth providers, as long as you meet the criteria, and can be fulfilled by mail-order pharmacies like NovoCare.
Why Aetna might deny Wegovy coverage
Not meeting BMI or comorbidity criteria is the most common reason Wegovy coverage may be denied. But other common reasons include:
- Incomplete or missing documentation
- Failure to obtain prior authorization before dispensing
- Exclusion of weight-loss medications from the plan
- Off-label use
- Not adhering to lifestyle changes
Tips for improving your chances of Wegovy approval
To lower your chances of rejection and make the approval process go more smoothly, consider:
- Collecting and submiting:
- BMI records and relevant medical history
- Documentation of prior weight-loss efforts
- Evidence of participation in a comprehensive weight-management program
- Regular weight-tracking logs
- Asking your provider to clearly document medical necessity
- If denied, consider submitting a formal appeal or medical exception through your HR department or benefits coordinator
Wegovy alternatives and savings if Aetna doesn’t cover it
If Aetna denies Wegovy coverage, you may want to try to lower your out-of-pocket cost or try an alternative medication.
- Wegovy Savings Card (From Novo Nordisk)
- Patients with commercial insurance may pay as little as $0/month (up to a $225 savings per month)
- New users (through July 2025): First month for $299, then $499/month
- Flat-rate cash pricing: $499/month for those without coverage
Note: Medicare and Medicaid patients are not eligible
2. NovoCare Pharmacy (Direct-to-Consumer Option)
- Delivers FDA-approved Wegovy directly to your home
- Cash price: $499/month for all doses
- Includes refill reminders and support services
3. Pharmacy Discount Tools
- Use platforms like GoodRx or SingleCare to compare prices
- Even with insurance, paying cash may be cheaper in some cases
4. Covered Alternatives Through Aetna
- Plenity (for BMI 25–40): Covered with lifestyle support
- Other options that may be included: Saxenda, Zepbound, Qsymia, and diethylpropion
How to get prior authorization from Aetna for Wegovy
- Contact Aetna or log in to your member portal to check if prior authorization is required for Wegovy.
- Ask your healthcare provider to complete and submit Aetna’s prior authorization (PA) form, including:
- Diagnosis of obesity or overweight with qualifying comorbidities (e.g., hypertension, type 2 diabetes)
- Current BMI and any relevant lab results
- Documentation of previous weight management efforts, including lifestyle changes and prior medications
- Proposed dosage and treatment plan. Your provider can submit the request electronically through Aetna’s provider or pharmacy portal.
- Follow up with Aetna if needed—PA decisions may take anywhere from a few business days to several weeks.
- If your request is denied, you can file an appeal with additional documentation or clarification from your provider.
Can you get Wegovy covered through Aetna?
Aetna may cover Wegovy, but approval typically requires meeting strict clinical guidelines and submitting detailed documentation. Prior authorization is almost always necessary, and incomplete records or missing pre-approval often lead to denials.
Fortunately, multiple cost-saving options and alternative treatments are available if coverage is denied. Telehealth services can simplify this process by helping you connect with a provider who understands the requirements and can efficiently manage the necessary paperwork.
Book an appointment on Klarity Health
Need help determining if your Aetna plan covers Wegovy? Klarity can assist you with benefit checks, documentation, and provider consultations. Book an appointment today.
Check if Wegovy is covered by your insurance
Speak with a provider through Klarity to explore your treatment options—coverage may vary by plan.
FAQs about Aetna Wegovy coverage
*Appointments are generally available within 24 hours. Free initial consultations are available only with select providers. Prescriptions, particularly for controlled substances, may require an in-person evaluation depending on the state of residence and current federal regulations.
The information provided in this article is for educational purposes only and should not be construed as medical advice. Always seek the guidance of a qualified healthcare professional with any questions or concerns you have regarding your health. Providers on Klarity Health are independent practitioners with clinical autonomy. Nothing in this article is intended to diagnose or treat any condition, including guaranteeing prescription medication of any kind or dosage. Not all providers on Klarity Health prescribe all medications, particularly medications that are controlled substances.
