Wegovy, a popular injectable medication, has transformed weight loss treatment for many adults struggling with obesity or weight-related health issues. As a GLP-1 receptor agonist, it helps reduce appetite and promote significant weight loss when combined with diet and exercise. However, its high cost makes insurance coverage a critical concern for potential users.
Aetna, a leading health insurance provider, offers various plans that may cover Wegovy, but coverage depends on specific plan details and medical necessity. With obesity rates rising and healthcare costs increasing, understanding Aetna’s policies on Wegovy is essential for those seeking this treatment. This article provides a detailed guide to help you navigate coverage options in 2025.
By exploring eligibility criteria, costs, and alternatives, this guide aims to simplify the process of accessing Wegovy through Aetna. Whether you’re starting your weight loss journey or exploring treatment options, this information will help you make informed decisions.
What Is Wegovy and How Does It Work?
Wegovy (semaglutide) is an FDA-approved weekly injection for chronic weight management in adults with obesity (BMI ≥30 kg/m²) or those overweight (BMI ≥27 kg/m²) with conditions like hypertension, type 2 diabetes, or dyslipidemia. It mimics the GLP-1 hormone, which regulates appetite and slows stomach emptying, leading to reduced hunger and increased fullness. Clinical trials show an average weight loss of 15% over 68 weeks when paired with lifestyle changes.
Wegovy is also approved to reduce cardiovascular risks, such as heart attack or stroke, in adults with heart disease and obesity or overweight. This dual indication may improve coverage chances for some Aetna plans. However, its retail cost—around $1,349-$1,847 per month without insurance—makes coverage vital for affordability.
Understanding Aetna’s Approach to Weight Loss Medications
Aetna’s coverage for weight loss drugs like Wegovy varies by plan, such as the Aetna Standard Plan or Advanced Control Plan. Some plans cover Wegovy under their Preferred Brand drug tier, while others exclude obesity treatments entirely. Coverage often requires prior authorization and proof of medical necessity.
To confirm coverage, check your plan’s formulary, a list of covered medications, available through Aetna’s member portal or customer service. Recent updates in 2025, particularly for cardiovascular risk reduction, have expanded coverage for some plans, especially for Medicare recipients with heart conditions.
Does Aetna Cover Wegovy for Weight Loss?
Aetna’s coverage for Wegovy for weight loss depends on your specific plan and its formulary. Some plans cover Wegovy for weight management with prior authorization, requiring a BMI of 30 kg/m² or higher, or 27 kg/m² with weight-related conditions like diabetes or hypertension. Others only cover it for cardiovascular risk reduction in patients with established heart disease.
In 2025, select Aetna plans, such as the Advanced Control Plan, began covering Wegovy for heart-related indications following FDA approval in March 2024. However, many plans still exclude weight loss medications or impose strict criteria. Always verify coverage by contacting Aetna or reviewing your plan documents.
Eligibility Criteria for Wegovy Coverage
Aetna’s requirements for Wegovy coverage align with FDA indications. Adults seeking coverage for weight loss typically need:
- A BMI of 30 kg/m² or higher (obesity) or 27 kg/m² with at least one weight-related condition (e.g., high blood pressure, type 2 diabetes).
- Participation in a six-month weight management program with diet, exercise, and behavioral changes.
- Prior authorization with medical documentation proving necessity.
For adolescents (12-17 years), coverage may apply if their BMI is at or above the 95th percentile for age and sex, with similar program participation. For cardiovascular risk reduction, coverage focuses on adults with heart disease and obesity or overweight.
Steps to Verify Wegovy Coverage with Aetna
Confirming whether your Aetna plan covers Wegovy involves a few key steps:
- Check Your Formulary: Access your plan’s drug list via Aetna’s member portal or app to see if Wegovy is included.
- Contact Member Services: Call the number on your insurance card (e.g., 1-855-582-2025) to inquire about coverage, copays, and prior authorization requirements.
- Consult Your Provider: Your doctor can confirm eligibility and submit necessary documentation for prior authorization.
- Review Plan Updates: Since coverage can change, verify details for 2025, especially for heart-related indications.
These steps ensure you understand your coverage and potential costs.
Costs and Savings Options for Wegovy
Without insurance, Wegovy costs between $1,349 and $1,847 for a one-month supply, making savings programs crucial. Aetna’s coverage, when available, may reduce costs to a copay (e.g., $25-$600, depending on the plan). Here are some savings options:
| Option | Description | Potential Savings |
|---|---|---|
| Wegovy Savings Card | Novo Nordisk offers this card, reducing costs to as low as $0-$25/month for eligible patients with commercial insurance. | Up to $1,847/month |
| SingleCare Coupons | Available at participating pharmacies, these can lower Wegovy’s price. | Up to $500/month |
| Manufacturer Assistance | Novo Nordisk’s programs may help uninsured or underinsured patients. | Varies, potentially full coverage |
If Aetna doesn’t cover Wegovy, these options can make the medication more affordable.
Handling Coverage Denials
If Aetna denies Wegovy coverage, you have several options:
- Appeal the Decision: Submit an appeal with your provider, including medical records and a letter of medical necessity. Appeals typically take 30 days.
- Request a Medical Exception: If other treatments are unsuitable, your doctor can request an exception.
- Explore Alternatives: Aetna may cover other medications like Saxenda or phentermine.
- Use Savings Programs: Manufacturer coupons or pharmacy discounts can reduce out-of-pocket costs.
Persistence and thorough documentation can improve your chances of approval.
Alternatives to Wegovy Covered by Aetna
If Wegovy isn’t covered, Aetna may cover other weight loss medications, including:
- Saxenda (liraglutide): A GLP-1 agonist, often covered with prior authorization.
- Phentermine (Adipex-P, Lomaira): A short-term option for obesity management.
- Qsymia: A combination drug for chronic weight management.
Each alternative has unique benefits and requirements, so discuss options with your provider to find the best fit.
Navigating the Prior Authorization Process
Prior authorization is often required for Wegovy coverage. To streamline the process:
- Compile a medical history of previous weight loss attempts, including diets and medications.
- Ensure your provider submits detailed documentation, such as BMI records and program participation.
- Follow up with Aetna to track your request’s status.
- Work with an obesity medicine specialist familiar with insurance protocols.
These steps can expedite approval and minimize delays.
Why Coverage Varies Across Plans
Aetna’s coverage decisions depend on factors like cost, clinical efficacy, and agreements with drug manufacturers. In 2025, expanded coverage for cardiovascular indications reflects FDA approvals and demand for GLP-1 agonists. Employer-sponsored plans may also influence coverage, as some opt out of weight loss medications to control costs. Understanding these factors can help you advocate for coverage.
Summary
Aetna’s coverage for Wegovy in 2025 varies by plan, with some covering it for weight loss or cardiovascular risk reduction, often requiring prior authorization and specific criteria like a BMI of 30 kg/m² or higher. Checking your plan’s formulary, consulting your provider, and exploring savings programs like the Wegovy Savings Card can help manage costs. If coverage is denied, appeals or alternatives like Saxenda may be viable. Staying proactive and informed is key to accessing Wegovy or similar treatments through Aetna.
FAQ
Does Aetna cover Wegovy for weight loss in 2025?
Coverage depends on your plan. Some Aetna plans cover Wegovy for weight loss with prior authorization, while others only cover it for cardiovascular risk reduction. Check your formulary or contact Aetna.
What criteria must I meet for Wegovy coverage?
You need a BMI of 30 kg/m² or higher (or 27 kg/m² with comorbidities), a six-month weight management program, and prior authorization with medical documentation.
What if Aetna denies Wegovy coverage?
Appeal with your provider, request a medical exception, explore alternatives like Saxenda, or use savings programs to reduce costs.
Are there ways to lower Wegovy’s cost?
Use the Wegovy Savings Card for as low as $0-$25/month, SingleCare coupons, or Novo Nordisk’s assistance programs for eligible patients.