Does Aetna cover Zepbound?

Are you wondering, “Does Aetna cover Zepbound?” Aetna might cover Zepbound (tirzepatide), but it depends on the particular Aetna plan and your circumstances.

During this guide, you’ll learn about eligibility criteria for Aetna coverage for Zepbound, how to know if your Aetna covers Zepbound, tips for improving your chances for approval, and more. Find a licensed provider on Klarity Health and get a telehealth appointment with a licensed healthcare provider within 24 hours.

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Does Aetna cover Zepbound?

Zepbound is an injectable prescription medication approved by the FDA for chronic weight management in adults with obesity or overweight adults with weight-related comorbidities. 

The medication is also FDA-approved for moderate to severe obstructive sleep apnea (OSA) in adults with obesity. OSA is a sleep disorder where your breathing stops and starts repeatedly while you’re sleeping due to a blockage in your airway. This blockage leads you to wake up briefly throughout the night, which can lead to daytime sleepiness and other health issues.

Zepbound is part of a medication class called dual glucose-dependent insulinotropic polypeptide (GIP)/glucagon-like peptide-1 (GLP-1) receptor agonists. GIP is a hormone that stimulates insulin release from your pancreas when you consume glucose. GLP-1 is another hormone that stimulates insulin release, reduces blood sugar levels by suppressing glucagon secretion, and promotes feelings of fullness. Dual GIP/GLP-1 receptor agonists, such as Zepbound, combine the effects of GIP and GLP-1 receptor activation to better control blood sugar levels.

Zepbound works for weight loss by mimicking the effects of GIP and GLP-1, which regulate blood sugar and appetite. The medication slows down the emptying of your stomach, which makes you feel full longer and helps your body process sugar better, often leading to decreased food intake and weight loss.

Wondering if Aetna covers Zepbound? Aetna often covers Zepbound for weight loss or OSA, but some Aetna plans require prior authorization and that you meet certain eligibility criteria.

Eligibility criteria for Aetna coverage for Zepbound

Aetna often requires prior authorization for Zepbound. Aetna coverage for Zepbound sometimes depends on meeting specific eligibility criteria related to body mass index (BMI), previous weight loss attempts, and previous participation in a comprehensive weight management program. 

Here are the eligibility criteria for some Aetna plans’ coverage for Zepbound:

BMI

You sometimes need a baseline BMI of at least 30 kilograms per meters squared (kg/m2). Some Aetna plans might cover Zepbound if you have a BMI of at least 27 kg/m2, as long as you also have at least 1 weight-related comorbidity, such as type 2 diabetes or hypertension.

Weight management program

You sometimes need to show that you’ve participated in a comprehensive weight management program for at least 6 months. This program must include increased physical activity, a reduced-calorie diet, and behavioral modification.

Prior authorization

Some Aetna plans require that you receive prior authorization for Zepbound. This means your licensed healthcare provider needs to submit documents that show you meet the eligibility criteria for Aetna coverage.

If you don’t meet these eligibility criteria, Aetna will sometimes cover other weight loss medications, such as Wegovy, as long as you meet specific criteria and receive prior authorization for those medications.

How to know whether my Aetna covers Zepbound

Here are a couple of the best ways to figure out whether your Aetna plan covers Zepbound:

Check the Aetna website or mobile app

• First, log in to your Aetna member account either through the secure website or mobile app.
• Navigate to the Find a Medication tool, then search for Zepbound or tirzepatide.
• Review the coverage details for Zepbound, including any restrictions or prior authorization requirements.
• Check the website for potential cost information for Zepbound, including coinsurance or copays.
• Check for information about retail pharmacy or mail-order options.

Contact Aetna directly

• Find the Aetna customer service phone number on the website or on your member ID card.
• Have your Aetna plan information and your member ID readily available to answer any questions about your coverage.
• Explain to the customer service representative that you’re wondering about your Aetna coverage for Zepbound.
• Ask the representative about specific details about coverage for Zepbound, including coinsurance, copays, restrictions, and prior authorization requests.
• Ask whether Zepbound is covered by your specific Aetna plan.

Does Aetna cover an online Zepbound prescription?

Whether Aetna covers an online Zepbound prescription depends on your particular Aetna plan and whether Zepbound is considered medically necessary for you. You need to check your plan’s medication list or formulary. You typically need to get prior authorization for an online Zepbound prescription.

Why Aetna might deny Zepbound coverage

Aetna might deny Zepbound coverage for a few reasons:

Not an FDA-approved indication

Zepbound is only FDA-approved to treat chronic weight management and OSA. If you want to use Mounjaro for an off-label use, Aetna might deny coverage for you.

No prior authorization

Aetna sometimes requires prior authorization for Zepbound, which means your prescribing provider needs to offer information about your medical history and treatment plan to Aetna for medication approval. If the prior authorization isn’t completed or the information doesn’t meet Aetna’s eligibility criteria, they can deny the claim.

Not a medical necessity

Aetna might deny coverage for Zepbound if they don’t consider it medically necessary for you, particularly if there are equally effective and less expensive medications available.

Not in the formulary

Check the formulary for your specific Aetna plan. If Zepbound isn’t listed as a covered medication in your specific plan, Aetna is more likely to deny coverage.

Tips for improving your chances of Zepbound approval

Here are a few tips for improving your chances of Zepbound approval:

Meet the eligibility criteria

You sometimes need to meet eligibility criteria to get Aetna coverage of Zepbound. These eligibility criteria include a BMI of at least 30 or a BMI of at least 27 with weight-related comorbidities, such as hypertension, type 2 diabetes, OSA, or high cholesterol, and previous participation in a structured weight management program.

Document your previous treatment history

Many health insurance plans require step therapy. Step therapy is a strategy where you try other less expensive medications first before Zepbound. They want documentation that you’ve tried other medications first, which have either failed or resulted in harsh, intolerable side effects. Make sure your medical documents clearly state the medications you tried, doses, treatment duration, and reasons for inadequate response or discontinuation.

Emphasize the effectiveness of Zepbound

Offer evidence of the effectiveness of Zepbound, particularly if you’ve already started the medication. Your doctor’s medical records and lab results should also note your positive response to Zepbound.

Alternatives and savings options if Aetna doesn’t cover Zepbound

If Aetna doesn’t cover Zepbound for you, you have several other options to consider:

Explore alternative medications to Zepbound

There are several other medications to consider besides Zepbound, including Mounjaro, other GLP-1 receptor agonists, and other weight loss medications.

Savings programs and options

• There are also many other savings options and programs if you can’t get coverage from Aetna.‘
• Manufacturer savings cards. You might be eligible for manufacturer savings cards if you have commercial insurance. These cards can decrease your out-of-pocket costs for Zepbound.
• Prescription discount cards. Platforms like GoodRx and SingleCare provide free discount cards that can reduce the cost of Zepbound at participating pharmacies.
• Patient assistance programs (PAPs). Pharmaceutical manufacturers often offer these PAPs, which provide discounted or free medications to underinsured or uninsured people who meet the eligibility requirements.
• Fill a 90-day supply. Getting a larger supply of Zepbound can help lower the overall cost of the medication.
• Community health centers offer affordable health care and typically have pharmacies that give you prescription medications either at lower costs or on a sliding scale based on your income.

Appeal Aetna’s decision

Your licensed healthcare provider might be able to appeal Aetna’s decision to deny coverage by offering documentation that proves the medical necessity of Zepbound for you. You can work with your provider to get documentation, including clinical notes and medical records, together to support your appeal.

How to get prior authorization from Aetna for Zepbound

Here’s what you need to do to get prior authorization from Aetna for Zepbound:

• Check the prior authorization requirements. First, you need to confirm through Aetna’s drug search tool or your Aetna plan’s formulary if Zepbound requires prior authorization for your particular Aetna plan.
• Get all the necessary documentation together. Work with your licensed healthcare provider to collect all of your medical records, including relevant lab results and diagnostic test results. You also need documentation of your BMI, any previous weight loss attempts, and that you’ve completed a structured, comprehensive weight management program.
• Have your provider submit the prior authorization request. Your licensed healthcare provider then needs to submit the prior authorization request either electronically or by phone. If your provider isn’t able to submit the request electronically, they can contact Aetna’s Precertification Department by using the phone number on your member ID card.
• Wait for a decision. Aetna usually processes prior authorization requests within 14 days or 2 weeks. Aetna will either approve or deny the request, or they might request additional information.

Key takeaways

Here are some of the key takeaways:

• Zepbound is an injectable prescription medication approved by the FDA for chronic weight management in adults with obesity or overweight adults with weight-related comorbidities. 
• The medication is also FDA-approved for moderate to severe obstructive sleep apnea (OSA) in adults with obesity. OSA is a sleep disorder where your breathing stops and starts repeatedly while you’re sleeping due to a blockage in your airway.
• Zepbound works for weight loss by mimicking the effects of GIP and GLP-1, which regulate blood sugar and appetite. The medication slows down the emptying of your stomach, which makes you feel full longer and helps your body process sugar better, often leading to decreased food intake and weight loss.
• Aetna often covers Zepbound for weight loss or OSA, but some Aetna plans require prior authorization and that you meet certain eligibility criteria.
• Aetna often requires prior authorization for Zepbound. Aetna coverage for Zepbound sometimes depends on meeting specific eligibility criteria related to body mass index (BMI), previous weight loss attempts, and previous participation in a comprehensive weight management program. 
• Whether Aetna covers an online Zepbound prescription depends on your particular Aetna plan and whether Zepbound is considered medically necessary for you. 

Book an appointment on Klarity Health

Ready to get a prescription for Zepbound? With Klarity Health, getting a telehealth appointment with a licensed healthcare provider is fast, simple, and convenient. You can simply connect with a provider from your own home and receive quality medical care in as little as 24 hours. The Klarity Health platform connects you with board-certified healthcare providers who follow clinical guidelines.

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