Obesity and overweight are significant health concerns, often requiring a multifaceted approach to management. Medications like Wegovy and Zepbound, alongside lifestyle modifications, have emerged as valuable tools in this fight. However, the cost of these medications can be a barrier, making insurance coverage a crucial factor. This article delves into the specifics of Aetna's weight loss coverage, focusing on medications like Wegovy and Zepbound, eligibility criteria, and strategies to maximize your chances of approval.
Understanding Aetna's Coverage for Weight Loss Medications
Aetna, a well-known health insurance provider, offers various plans with different levels of coverage for weight loss treatments. It's essential to understand that coverage can vary significantly depending on your specific plan.
Wegovy Coverage Details
Wegovy (semaglutide) is an injectable medication approved by the Food and Drug Administration (FDA) for chronic weight management. It's designed to be used in conjunction with a reduced-calorie diet and increased physical activity.
Does Aetna Cover Wegovy?
Yes, some Aetna health insurance plans cover Wegovy. Aetna follows FDA-approved indications for Wegovy prescriptions, requiring adults to take the drug alongside a reduced-calorie diet and increased physical activity for chronic weight management.
Prior Authorization
Some Aetna plans might require prior authorization for Wegovy. This means that Aetna needs to determine if the medication is medically necessary for you. To streamline this process, provide comprehensive details to your healthcare provider, including the dates you started and stopped any previous weight loss programs or medications, their effectiveness, any side effects experienced, and reasons for discontinuation.
Read also: Does Aetna Cover Weight Loss Drugs?
Cost Considerations
Without insurance or coupons, Wegovy can be expensive, typically costing around $1,847 for a one-month supply. However, insurance coverage can significantly reduce this cost, and Aetna's prescription drug coverage finder can help you determine your specific plan's coverage. Novo Nordisk, the manufacturer of Wegovy, also offers an online tool to check your cost and coverage. Additionally, SingleCare coupons can potentially lower the cost of Wegovy by close to $600 per month, depending on the pharmacy.
Zepbound Coverage Details
Zepbound (tirzepatide) is another injectable prescription medication approved by the FDA for chronic weight management in adults with obesity or overweight adults with weight-related comorbidities. It is also FDA-approved for moderate to severe obstructive sleep apnea (OSA) in adults with obesity.
Does Aetna Cover Zepbound?
Aetna often covers Zepbound for weight loss, but some plans require prior authorization and meeting specific eligibility criteria.
How Zepbound Works
Zepbound belongs to a class of medications called dual glucose-dependent insulinotropic polypeptide (GIP)/glucagon-like peptide-1 (GLP-1) receptor agonists. These medications mimic the effects of GIP and GLP-1, hormones that regulate blood sugar and appetite. Zepbound slows down stomach emptying, promoting feelings of fullness and improving sugar processing, which can lead to decreased food intake and weight loss.
Eligibility Criteria for Zepbound Coverage
Aetna coverage for Zepbound for weight loss often depends on meeting specific criteria:
Read also: Aetna Healthy Foods Card: A Guide
- BMI: A baseline BMI of at least 30 kg/m2 is often required. Some plans may cover Zepbound with a BMI of at least 27 kg/m2 if you also have at least one weight-related comorbidity, such as type 2 diabetes or hypertension.
- Weight Management Program: You may need to demonstrate participation in a comprehensive weight management program for at least 6 months, including increased physical activity, a reduced-calorie diet, and behavioral modification.
- Prior Authorization: Many Aetna plans require prior authorization for Zepbound.
Reasons for Zepbound Coverage Denial
Aetna might deny Zepbound coverage for several reasons:
- No Prior Authorization: If prior authorization is required and not completed, or if the information provided doesn't meet Aetna's eligibility criteria, the claim can be denied.
- Not a Medical Necessity: Aetna may deny coverage if they don't consider Zepbound medically necessary, especially if equally effective and less expensive alternatives are available.
- Not in the Formulary: If Zepbound isn't listed as a covered medication in your specific plan's formulary, coverage is more likely to be denied.
Maximizing Your Chances of Approval
To increase your chances of getting Aetna to cover Wegovy or Zepbound for weight loss, consider the following tips:
Meeting Eligibility Criteria
Ensure you meet the specific eligibility criteria for your Aetna plan. This often includes having a BMI of at least 30 or a BMI of at least 27 with weight-related comorbidities like hypertension, type 2 diabetes, or obstructive sleep apnea. Documented participation in a structured weight management program is also crucial.
Documenting Previous Treatment History
Many insurance plans require step therapy, meaning you need to try other, less expensive medications first. Provide clear documentation of any medications you've tried, including dosages, treatment duration, and reasons for inadequate response or discontinuation.
Emphasizing the Effectiveness of the Medication
If you've already started Wegovy or Zepbound, provide evidence of its effectiveness. Your doctor's medical records and lab results should reflect your positive response to the medication.
Read also: Aetna Healthy Benefits Guide
Prior Authorization Process for Zepbound
Here's how to navigate the prior authorization process for Zepbound with Aetna:
- Check Requirements: Confirm if Zepbound requires prior authorization for your specific Aetna plan using Aetna's drug search tool or your plan's formulary.
- Gather Documentation: Work with your healthcare provider to collect all necessary medical records, including lab results, diagnostic test results, BMI documentation, previous weight loss attempts, and proof of completion of a structured weight management program.
- Submit the Request: Have your healthcare provider submit the prior authorization request electronically or by phone. If electronic submission isn't possible, your provider can contact Aetna's Precertification Department using the phone number on your member ID card.
- Wait for a Decision: Aetna typically processes prior authorization requests within 14 days. They will either approve or deny the request or may ask for additional information.
Exploring Alternatives and Savings Options
If Aetna doesn't cover Wegovy or Zepbound, or while you are waiting for approval, explore these alternative strategies:
Alternative Medications
Discuss other weight loss medications with your healthcare provider. Options include Mounjaro (also containing tirzepatide), other GLP-1 receptor agonists like Ozempic (semaglutide) and Saxenda (liraglutide), and other weight loss medications like phentermine, Qsymia (phentermine-topiramate), Contrave (naltrexone-bupropion), Xenical (orlistat), and Alli (orlistat).
Savings Programs and Options
- Manufacturer Savings Cards: Check if you're eligible for manufacturer savings cards, which can lower your out-of-pocket costs for Wegovy or Zepbound if you have commercial insurance.
- Prescription Discount Cards: Use platforms like GoodRx and SingleCare to find free discount cards that can reduce the cost of the medication at participating pharmacies.
- Patient Assistance Programs (PAPs): Pharmaceutical manufacturers often offer PAPs that provide discounted or free medications to underinsured or uninsured individuals who meet the eligibility requirements.
- 90-Day Supply: Consider filling a 90-day supply of the medication to potentially lower the overall cost.
- Community Health Centers: These centers offer affordable healthcare and often have pharmacies that provide prescription medications at lower costs or on a sliding scale based on your income.
Appealing Aetna's Decision
If Aetna denies coverage, your healthcare provider can appeal the decision by providing documentation that proves the medical necessity of Wegovy or Zepbound for you. Work with your provider to gather clinical notes and medical records to support your appeal.
Aetna's Additional Resources for Weight Management
Beyond medication coverage, Aetna provides various resources to support weight management:
- Weight Reduction Counseling: Aetna considers up to 26 individual or group visits per 12-month period as medically necessary for weight reduction counseling in adults who are obese (BMI greater than or equal to 30 kg/m2).
- Intensive Multicomponent Behavioral Interventions: Aetna supports intensive behavioral interventions that combine dietary changes and increased physical activity to help participants achieve or maintain weight loss.
- Online Health Coaching Programs: Aetna's Simple Steps To A Healthier Life® online health coaching programs offer personalized plans, convenient tools, and online coaching sessions to help you succeed in your health goals.
- Discounts on Health and Wellness Services: Aetna members can access discounts on gym memberships, health coaches, nutrition products, massage therapy, acupuncture, chiropractic visits, and vision and hearing care.
- Zero Cost Programs: Aetna Personal Health Solutions offers weight-loss programs that can help reduce your risk for type 2 diabetes and heart conditions, providing tools designed to work with your lifestyle.
Lifestyle Modifications: A Cornerstone of Weight Management
It's crucial to remember that medications like Wegovy and Zepbound are most effective when combined with lifestyle modifications. These modifications include:
- Caloric Restriction: Reducing your daily calorie intake is essential for weight loss.
- Increased Physical Activity: Regular exercise helps burn calories and improve overall health.
- Behavioral Modification: Addressing underlying behavioral patterns that contribute to overeating is crucial for long-term success.
Other Weight Loss Medications and Considerations
Aetna's coverage policies extend to several other weight loss medications, each with its own set of criteria and limitations. These include:
- Adipex-P (phentermine), Lomaira (phentermine), Phentermine: These are indicated as short-term adjuncts to a weight reduction regimen based on exercise, behavioral modification, and caloric restriction for patients with a BMI of 30 kg/m2 or greater, or 27 kg/m2 or greater with risk factors.
- Benzphetamine: This is indicated for short-term use in managing exogenous obesity in patients with a BMI of 30 kg/m2 or higher who haven't responded to diet and exercise alone.
- Contrave (naltrexone/bupropion extended-release): This is indicated as an adjunct to diet and exercise for chronic weight management in adults with a BMI of 30 kg/m2 or greater, or 27 kg/m2 or greater with comorbidities.
- Diethylpropion: This is for short-term management of exogenous obesity in patients with a BMI of 30 kg/m2 or higher who haven't responded to diet and exercise.
- Phendimetrazine: This is indicated for short-term use in managing exogenous obesity in patients with a BMI of 30 kg/m2 or greater, or 27 kg/m2 or greater with risk factors.
- Qsymia (phentermine/topiramate extended-release): This is indicated as an adjunct to diet and exercise for chronic weight management in adults and pediatric patients aged 12 years and older with specific BMI criteria.
- Xenical (orlistat): This is indicated for obesity management, including weight loss and maintenance, when used with a reduced-calorie diet.
The Importance of a Multidisciplinary Approach
Effective weight management often requires a multidisciplinary approach involving healthcare providers, dietitians, and behavioral therapists. Aetna recognizes the importance of this approach and provides coverage for various services, including:
- Dietetic Counseling: Aetna recommends dietetic counseling and behavioral modification before and after obesity surgery.
- Pre-operative Assessment: Aetna supports pre-operative assessments for cardiovascular, pulmonary, gastrointestinal, endocrine, and other obesity-related diseases.
- Post-operative Education: Aetna emphasizes the importance of post-operative education and counseling by a registered dietitian.
- Psychological Clearance: For members with active substance abuse disorders, eating disorders, or severe psychiatric disturbances, pre-operative psychological clearance is necessary.