Unlock Aetna Weight Loss Drug Coverage: Your Ultimate Comprehensive Guide

Obesity and being overweight are serious global health concerns, with a rapidly increasing prevalence that poses a significant threat to healthcare systems. Aetna, like many health insurance providers, has specific policies regarding coverage for weight loss medications. This article aims to provide a detailed overview of Aetna's weight loss drug coverage policy, including covered medications, eligibility criteria, and other important considerations.

General Coverage Exclusions

It's important to note that many Aetna plan benefit descriptions specifically exclude services and supplies for or related to treatment of obesity or for diet and weight control. Under these plans, claims for weight reduction medications and for physician supervision of weight reduction programs will be denied based on that exclusion. In addition, many Aetna benefit plans specifically exclude coverage of weight reduction medications under the pharmacy benefit and/or under the health benefits plan. The medical necessity criteria do not apply to health plans that specifically exclude services and supplies for or related to treatment of obesity or for diet or weight control.

Weight Reduction Counseling

Aetna considers up to a combined limit of 26 individual or group visits by any recognized provider per 12-month period as medically necessary for weight reduction counseling in adults who are obese (as defined by BMI greater than or equal to 30 kg/m2).

General Guidelines for Weight Reduction Medications

Weight reduction medications should be used as an adjunct to caloric restriction, exercise, and behavioral modification, when these measures alone have not resulted in adequate weight loss. Weight loss due to weight reduction medication use is generally temporary. In addition, the potential for development of physical dependence and addiction is high. Individuals who cannot maintain weight loss through behavioral weight loss therapy and are at risk of medical complications of obesity are an exception to this; for these persons, the risk of physical dependence or other adverse effects may present less of a risk than continued obesity.

Tests with weight loss drugs have shown that initial responders tend to continue to respond, while initial non-responders are less likely to respond even with an increase in dosage. If a person does not lose 2 kg (4.4 lbs) in the first four weeks after initiating therapy, the likelihood of long-term response is very low.

FDA-Approved Weight Loss Medications and Aetna Coverage

Aetna's coverage policies are often aligned with FDA-approved indications for weight loss medications. The following is a list of FDA-approved weight loss medications and their indications, along with Aetna's coverage criteria:

Adipex-P (phentermine), Lomaira (phentermine), Phentermine

Indication: Short-term adjunct in a regimen of weight reduction based on exercise, behavioral modification, and caloric restriction in the management of exogenous obesity for patients with an initial body mass index greater than or equal to 30 kg/m2, or greater than or equal to 27 kg/m2 in the presence of other risk factors (e.g., controlled hypertension, diabetes, hyperlipidemia).
Aetna Coverage Criteria: The patient has NOT received 3 months of therapy or more with the requested drug in the past 365 days.

Benzphetamine (Didrex)

Indication: Short-term adjunct in the management of exogenous obesity as a short term (a few weeks) adjunct in a regimen of weight reduction based on caloric restriction in patients with an initial body mass index (BMI) of 30 kg/m2 or higher who have not responded to appropriate weight reducing regimen (diet and/or exercise) alone.
Contraindications: Advanced arteriosclerosis, symptomatic cardiovascular disease, moderate to severe hypertension, hyperthyroidism, known hypersensitivity or idiosyncrasy to sympathomimetic amines, and glaucoma. Benzphetamine should not be given to patients who are in an agitated state or who have a history of drug abuse. Hypertensive crises have resulted when sympathomimetic amines have been used concomitantly or within 14 days following use of monoamine oxidase inhibitors. Didrex should not be used concomitantly with other CNS stimulants. Didrex may cause fetal harm when administered to a pregnant woman. Didrex is contraindicated in women who are or may become pregnant. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to the fetus. Didrex should not be used in combination with other anorectic agents, including prescribed drugs, over-the-counter preparations and herbal products. Valvular heart disease associated with the use of some anorectic agents such as fenfluramine and dexfenfluramine has been reported. Possible contributing factors include use for extended periods of time, higher than recommended dose, and/or use in combination with other anorectic drugs.
Aetna Coverage Criteria: The patient has NOT received 3 months of therapy or more with the requested drug in the past 365 days.

Contrave (naltrexone/bupropion extended-release)

Indication: Adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of: 30 kg/m2 or greater (obese) or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, or dyslipidemia).
Limitations of Use: The effect of Contrave on cardiovascular morbidity and mortality has not been established. The safety and effectiveness of Contrave in combination with other products intended for weight loss, including prescription drugs, over-the-counter drugs, and herbal preparations, have not been established.

Diethylpropion (extended and immediate release)

Indication: Short-term adjunct in the management of exogenous obesity as a short-term adjunct (a few weeks) in a regimen of weight reduction based on caloric restriction in patients with an initial body mass index (BMI) of 30 kg/m2 or higher and who have not responded to appropriate weight reducing regimen (diet and/or exercise) alone.

Phendimetrazine (extended and immediate release)

Indication: Short term adjunct (a few weeks) in a regimen of weight reduction based on caloric restriction in patients with an initial body mass index (BMI) of greater than or equal to 30 kg/m2 or greater than or equal to 27 kg/m2 in the presence of other risk factors (e.g., controlled hypertension, diabetes, hyperlipidemia) who have not responded to appropriate weight reducing regimen (diet and/or exercise) alone.

Qsymia (phentermine/topiramate extended-release)

Indication: Adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in: Adults with an initial body mass index (BMI) of: ° 30 kg/m2 or greater (obese), or ° 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity such as hypertension, type 2 diabetes mellitus, or dyslipidemia. Pediatric patients aged 12 years and older with an initial BMI in the 95th percentile or greater standardized for age and sex.
Limitations of Use: The effect of Qsymia on cardiovascular morbidity and mortality has not been established. The safety and effectiveness of Qsymia in combination with other products intended for weight loss, including prescription drugs, over-the-counter drugs, and herbal preparations, have not been established.
Aetna Coverage Criteria (Pediatric): The patient has an initial body mass index (BMI) in the 95th percentile or greater standardized for age and sex.

Saxenda (liraglutide)

Indication: Adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in: Adult patients with an initial body mass index (BMI) of: ° 30 kg/m2 or greater (obese), or ° 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, or dyslipidemia). Pediatric patients aged 12 years and older with: ° body weight above 60 kg and ° an initial BMI corresponding to 30 kg/m2 or greater for adults (obese) by international cut-offs (Cole Criteria)
Limitations of Use: Saxenda contains liraglutide and should not be coadministered with other liraglutide-containing products or with any other GLP-1 receptor agonist. The safety and effectiveness of Saxenda in pediatric patients with type 2 diabetes have not been established. The safety and effectiveness of Saxenda in combination with other products intended for weight loss, including prescription drugs, over-the-counter drugs, and herbal preparations, have not been established.
Aetna Coverage Criteria (Pediatric): The patient has a body weight above 60 kg and The patient has an initial BMI corresponding to 30 kg/m2 or greater for adults (obese) by international cut-offs (Cole Criteria)

Wegovy (semaglutide)

Indication: In combination with a reduced calorie diet and increased physical activity: to reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) in adults with established cardiovascular disease and either obesity or overweight. to reduce excess body weight and maintain weight reduction long term in: Adults and pediatric patients aged 12 years and older with obesity. Adults with overweight in the presence of at least one weight-related comorbid condition.
Limitation of Use: Wegovy contains semaglutide. Coadministration with other semaglutide-containing products or with any other GLP-1 receptor agonist is not recommended.
Aetna Coverage Criteria: The requested drug will be covered with prior authorization when the following criteria are met: The requested drug will be used with a reduced calorie diet and increased physical activity to reduce excess body weight and maintain weight reduction long term AND ° The patient is 18 years of age or older AND The patient has participated in a comprehensive weight management program that encourages behavioral modification, reduced calorie diet, and increased physical activity with continuing follow-up for at least 6 months prior to using drug therapy AND ° The patient has a baseline body mass index (BMI) greater than or equal to 30 kg/m2. OR The patient has a baseline body mass index (BMI) greater than or equal to 27 kg/m2. AND The patient has at least one weight related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, dyslipidemia). OR The patient has completed at least 3 months of therapy with the requested drug at a stable maintenance dose AND The patient has lost at least 5 percent of baseline body weight OR the patient has continued to maintain their initial 5 percent weight loss. OR The patient is 12 to 17 years of age AND The patient has participated in a comprehensive weight management program that encourages behavioral modification, reduced calorie diet, and increased physical activity with continuing follow-up for at least 6 months prior to using drug therapy AND The patient has a baseline body mass index (BMI) in the 95th percentile or greater standardized for age and sex (obesity). OR The request is for continuation of therapy for a patient that has successfully titrated to a stable maintenance dose AND The patient has had a reduction from their baseline body mass index (BMI) OR the patient has continued to maintain their reduction in BMI from baseline.
Aetna Coverage Criteria (Risk Reduction of Major Adverse Cardiovascular Events): The requested drug will be used to reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) in an adult with established cardiovascular disease AND either obesity or overweight AND The requested drug is being used with a reduced calorie diet and increased physical activity AND The request is NOT for continuation of therapy AND The patient has established cardiovascular disease with a history of ONE of the following: A) previous myocardial infarction (MI), B) previous stroke, C) symptomatic peripheral arterial disease (PAD), as evidenced by intermittent claudication with ankle- brachial index (ABI) less than 0.85 (at rest), peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease, D) prior history of revascularization (coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or angioplasty). AND The patient has a baseline body mass index (BMI) greater than or equal to 27 kg/m2. AND The patient does NOT have type 2 diabetes. The patient is currently receiving guideline-directed management and therapy (GDMT) for cardiovascular disease OR the patient has clinical reason not to be treated with GDMT for cardiovascular disease (e.g., lipid-lowering agent, antiplatelet, beta- blocker, renin-angiotensin inhibitor, etc.).

Xenical (orlistat)

Indication: Obesity management including weight loss and weight maintenance when used in conjunction with a reduced-calorie diet. Xenical is also indicated to reduce the risk for weight regain after prior weight loss. Xenical is indicated for obese patients with an initial body mass index (BMI) greater than or equal to 30 kg/m2 or greater than or equal to 27 kg/m2 in the presence of other risk factors (e.g., hypertension, diabetes, dyslipidemia).

Zepbound (tirzepatide)

Indication: Adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of: 30 kg/m2 or greater (obesity) or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition (e.g., hypertension, dyslipidemia, type 2 diabetes mellitus, obstructive sleep apnea, or cardiovascular disease).
Limitations of Use: Zepbound contains tirzepatide. Coadministration with other tirzepatide-containing products or with any glucagon-like peptide-1 (GLP-1) receptor agonist is not recommended. The safety and efficacy of Zepbound in combination with other products intended for weight management, including prescription drugs, over-the-counter drugs, and herbal preparations, have not been established. Zepbound has not been studied in patients with a history of pancreatitis.

Coverage Criteria Details

Aetna's coverage criteria often include specific requirements related to:

Body Mass Index (BMI): Aetna often requires a BMI of 30 kg/m2 or greater for coverage. Some plans may cover medications for individuals with a BMI of 27 kg/m2 or greater if they have at least one weight-related comorbidity.
Comprehensive Weight Management Program: Aetna often requires that patients participate in a comprehensive weight management program that includes a reduced-calorie diet, increased physical activity, and behavioral modification for a specified period (e.g., 6 months) prior to initiating drug therapy.
Prior Authorization: Many Aetna plans require prior authorization for weight loss medications. This means that the prescribing provider must submit information about the patient's medical history and treatment plan to Aetna for approval.
Age Restrictions: Some weight loss medications have age restrictions, as indicated by the FDA-approved labeling.
Contraindications: Aetna will not cover medications if the patient has any contraindications to the requested drug, as outlined in the drug's labeling.
FDA-Approved Indication: The requested drug must be used for an FDA-approved indication.
Comorbid Conditions: For some medications, Aetna may require the presence of one or more comorbid conditions, such as cardiovascular disease, hypertension, dyslipidemia, diabetes, or sleep apnea.
Prior Therapy: Some Aetna policies stipulate that the patient must not have received therapy with the requested drug for a certain period (e.g., 3 months) in the past year.
Weight Loss Documentation: For continuation of therapy, Aetna may require documentation of a certain percentage of weight loss (e.g., 5% of baseline body weight) or maintenance of initial weight loss.
Exclusion of Dual Therapy: Aetna typically does not cover patients receiving two drugs for weight loss at the same time.

Why Aetna Might Deny Coverage

Aetna might deny Zepbound coverage for weight loss for a few reasons:

No prior authorization. Aetna sometimes requires prior authorization for Zepbound for weight loss, 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 for weight loss 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 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 for weight loss. 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.

Coverage for Risk Reduction of Major Adverse Cardiovascular Events

Aetna may grant authorization for Wegovy (semaglutide) when prescribed to reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction (MI), or non-fatal stroke) in an adult with established cardiovascular disease AND either obesity or overweight, provided that certain criteria are met.

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These criteria include:

The patient must have established cardiovascular disease with a history of previous MI, previous stroke, symptomatic peripheral arterial disease (PAD), or prior history of revascularization.
The patient must have a baseline body mass index (BMI) greater than or equal to 27 kg/m2.
The patient must NOT have type 2 diabetes.
The patient must be currently receiving guideline-directed management and therapy (GDMT) for cardiovascular disease or have a clinical reason not to be treated with GDMT.

Alternatives and Savings Options

If Aetna denies coverage for a particular weight loss medication, individuals have several options to consider:

Explore Alternative Medications: Discuss alternative weight loss medications with your healthcare provider. There are several other medications to consider besides Zepbound for weight loss, including Mounjaro, other GLP-1 receptor agonists, and other weight loss medications.
Savings Programs and Options: 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 offer prescription discount cards that can lower the cost of medications.

Additional Considerations

Clinical Policy Bulletins (CPBs): Aetna develops Clinical Policy Bulletins (CPBs) to assist in administering plan benefits. These CPBs do not constitute medical advice, and treating providers are solely responsible for medical advice and treatment of members. Members should discuss any CPB related to their coverage or condition with their treating provider.
Medical Necessity Determinations: While CPBs define Aetna's clinical policy, medical necessity determinations in connection with coverage decisions are made on a case-by-case basis.
Appeals Process: In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision.

Read also: Aetna Healthy Benefits Guide

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