Does Aetna cover Wegovy?

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

So, 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 typically required. This often means providing medical documentation, such as a specific body mass index (BMI), and proof of previous weight loss attempts. Coverage may also depend on state regulations and employer-specific exclusions. 

When Aetna does cover Wegovy, it typically abides by the drug’s indications approved by the US Food and Drug Administration (FDA). 

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, but in general, Aetna follows the indications approved by the US Food and Drug Administration (FDA) for Wegovy.

Adults ages 18 and older 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).

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 12–17 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 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 with a Medicare Prescription Drug Plan through Aetna can visit this website instead.  

Another option is to use Ro’s GLP-1 Insurance Coverage Checker, a free and accessible online tool for all (read: not just Ro patients). Simply fill out the form with the information on your insurance card, and Ro will send you a free, personalized coverage report based on their conversation with your plan.

Without insurance or discounts, Wegovy typically costs $1,349.02 for a one-month supply (i.e. four pre-filled, single-dose injector pens). But that’s just the list price; the actual cost can vary depending on factors such as your preferred pharmacy and location. 

What about if your Aetna plan does, in fact, cover Wegovy? Your out-of-pocket cost will depend on your specific plan’s formulary and copay structure as well as your deductible status.  

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 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. 

As mentioned above, 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. If your insurance covers Wegovy, the savings offer can lower your out-of-pocket cost to as little as $0 per month, with a maximum savings of $225 per 28-day supply. (Yes, that means you may be able to get Wegovy for free.) If your insurance does not cover Wegovy, the manufacturer’s offer brings the cost of the drug 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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While some Aetna plans include Wegovy, others exclude weight loss medications entirely. Knowing what steps to take—whether it’s securing prior authorization, checking your benefits, or exploring cost-saving options—can help you navigate the process more effectively. Here, some key takeaways to keep in mind:

• Aetna’s coverage for Wegovy varies by plan—some cover it with prior authorization, while others exclude weight loss medications altogether. 

• If your Aetna plan covers Wegovy, you’ll likely need to meet specific criteria, such as a BMI requirement or documented weight loss efforts.

• If your Aetna plan doesn’t cover Wegovy, you may be able to appeal the decision, explore alternative weight loss medications, or use savings programs to lower costs.