Unlock Aetna's Weight Loss Medication Coverage: What You Need to Know Now!

Aetna offers various plans with different coverage policies for weight loss medications. This article provides a detailed overview of Aetna's coverage policies for weight loss medications, including specific drugs, eligibility criteria, and tips for improving your chances of approval.

FDA-Approved Indications for Weight Loss Medications

Several weight loss medications have received FDA approval for specific uses. These medications are typically intended to be used as part of a comprehensive weight management program that includes a reduced-calorie diet, increased physical activity, and behavioral modifications.

Here's a breakdown of some FDA-approved indications for frequently covered weight loss medications:

Wegovy (semaglutide): Wegovy is indicated 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.
Zepbound (tirzepatide): Zepbound is indicated as an 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).
Saxenda (liraglutide): Saxenda is indicated as an 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)
Contrave (naltrexone/bupropion extended-release): Contrave is indicated as an 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).
Qsymia (phentermine/topiramate extended-release): Qsymia is indicated as an 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.
Xenical (orlistat): Xenical is indicated for 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).
Adipex-P (phentermine), Lomaira (phentermine), Phentermine: Phentermine is indicated as a short-term (a few weeks) 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).
Benzphetamine: Benzphetamine hydrochloride tablets, USP are indicated 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.
Diethylpropion (extended and immediate release): Diethylpropion is indicated 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 release): Phendimetrazine tartrate is indicated 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 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.
Phendimetrazine (immediate release): Phendimetrazine tartrate is indicated 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 who have not responded to appropriate weight reducing regimen (diet and/or exercise) alone.

It's important to note the limitations of use for certain medications. For example, Wegovy contains semaglutide, and coadministration with other semaglutide-containing products or any other GLP-1 receptor agonist is not recommended. Similarly, Zepbound contains tirzepatide, and coadministration with other tirzepatide-containing products or with any glucagon-like peptide-1 (GLP-1) receptor agonist is not recommended.

Coverage Criteria for Weight Loss Medications

Aetna's coverage for weight loss medications often depends on specific criteria, including age, BMI, participation in a weight management program, and the presence of comorbid conditions. Prior authorization is frequently required.

General Requirements

Regardless of the specific medication, Aetna typically requires that:

The patient is actively enrolled in a weight loss program that involves a reduced-calorie diet and increased physical activity adjunct to therapy.
The patient's age is appropriate according to FDA labeling of the requested drug.
The patient is NOT receiving TWO drugs for weight loss at the same time.
The patient does NOT have ANY contraindications to the requested drug.
The requested drug is being used for an FDA-approved indication.

Specific Criteria for Adults

For adults, Aetna may grant authorization for weight loss medications when:

The patient is 18 years of age or older.
The patient has participated in a comprehensive weight management program that encourages behavioral modification, a reduced-calorie diet, and increased physical activity with continuing follow-up for at least 6 months prior to using drug therapy.
The patient has a baseline body mass index (BMI) greater than or equal to 35 kg/m2.

In some cases, Aetna may cover weight loss medications if the patient has a BMI of at least 27 kg/m2 and at least one weight-related comorbidity, such as hypertension, type 2 diabetes, dyslipidemia, obstructive sleep apnea, or cardiovascular disease.

Specific Criteria for Pediatrics

For pediatric patients (ages 12-17), Aetna may grant authorization for Saxenda or Wegovy when:

The patient is 12 to 17 years of age.
The patient has participated in a comprehensive weight management program that encourages behavioral modification, a reduced-calorie diet, and increased physical activity with continuing follow-up for at least 6 months prior to using drug therapy.
If the request is for Saxenda (liraglutide), then ALL of the following criteria are met:
- The patient has a body weight above 60 kg
- The patient has a baseline body mass index (BMI) corresponding to 30 kg/m2 or greater for adults by international cut-off points based on the Cole Criteria
If the request is for Wegovy (semaglutide), then the following criteria is met:
- The patient has a baseline BMI in the 95th percentile or greater standardized for age and sex (obesity)

Risk Reduction of Major Adverse Cardiovascular Events (Adult) â Wegovy ONLY

Authorization may be granted when the requested drug will be used 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 when ALL of the following criteria are met:

Read also: Aetna Healthy Foods Card: A Guide

The request is for Wegovy (semaglutide)
The requested drug is being used with a reduced calorie diet and increased physical activity
The patient has established cardiovascular disease with a history of ONE of the following: previous MI; previous stroke; 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; prior history of revascularization (coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or angioplasty)
The patient has a baseline body mass index (BMI) greater than or equal to 27 kg/m2
The patient does NOT have type 2 diabetes

Additional Considerations for Specific Medications

Adipex-P (phentermine), benzphetamine, diethylpropion, Lomaira (phentermine), phendimetrazine, or phentermine: The patient has NOT received 3 months of therapy or more with the requested drug in the past 365 days.

Why Aetna Might Deny Coverage

Aetna might deny coverage for weight loss medications for several reasons:

Lack of Prior Authorization: If prior authorization is required and not obtained, the claim will likely be denied.
Not Meeting Medical Necessity: Aetna may not consider the medication medically necessary, especially if there are equally effective and less expensive alternatives.
Not in Formulary: If the medication is not listed as a covered drug in your specific Aetna plan's formulary, coverage is unlikely.
Failure to Meet Eligibility Criteria: If you don't meet the specific BMI, weight management program participation, or comorbidity requirements, your request may be denied.
Exclusion in Benefit Plan: Many Aetna benefit plans 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.

Tips for Improving Your Chances of Approval

To increase your chances of getting Aetna coverage for weight loss medications:

Meet the Eligibility Criteria: Ensure you meet all the required criteria, including BMI, participation in a weight management program, and presence of comorbidities.
Document Your Previous Treatment History: Provide documentation of previous weight loss attempts, including diets, exercise programs, and other medications you've tried. 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 youâve 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 the Medication: If you've already started the medication, provide evidence of its effectiveness, such as weight loss progress and improvements in health markers. Your doctorâs medical records and lab results should also note your positive response to Zepbound.
Prior Authorization: Work with your healthcare provider to obtain prior authorization if required. This involves submitting your medical history and treatment plan to Aetna for approval.
Appeal a Denial: If your request is denied, work with your provider to appeal the decision. Provide additional documentation and information to support your case, including clinical notes and medical records, together to support your appeal.

How to Get Prior Authorization from Aetna

Check Requirements: Verify if your Aetna plan requires prior authorization for the specific weight loss medication.
Gather Documentation: Collect all necessary medical records, including lab results, diagnostic test results, BMI documentation, previous weight loss attempts, and proof of participation in a structured weight management program.
Submit Request: Have your healthcare provider submit the prior authorization request electronically or by phone.
Wait for Decision: Aetna typically processes prior authorization requests within 14 days. They will either approve, deny, or request additional information.

Alternatives and Savings Options

If Aetna doesn't cover your weight loss medication, consider these alternatives:

Explore Alternative Medications: Discuss other weight loss medications with your doctor, such as Mounjaro, Ozempic, Wegovy, Saxenda, phentermine, Qsymia, Contrave, Xenical, or Alli.
Savings Programs and Options: Check for manufacturer savings cards or patient assistance programs that can lower your out-of-pocket costs.
Prescription Discount Cards: Use platforms like GoodRx and SingleCare to find free discount cards for reduced medication costs.
90-Day Supply: If possible, get a 90-day supply of the medication to lower the overall cost.
Community Health Centers: Explore community health centers for affordable healthcare and prescription medications.

The Role of Weight Management Programs

Aetna often emphasizes the importance of comprehensive weight management programs. These programs typically include:

Behavioral Modification: Strategies to change eating habits and behaviors related to food.
Reduced-Calorie Diet: A diet plan designed to reduce calorie intake and promote weight loss.
Increased Physical Activity: Regular exercise to burn calories and improve overall health.
Continuing Follow-Up: Ongoing support and monitoring to help maintain weight loss.

Participation in such a program for at least 6 months is often a prerequisite for Aetna coverage of weight loss medications.

Read also: Aetna Healthy Benefits Guide

Specific Medications and Aetna Coverage

Zepbound (tirzepatide)

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 OSA in adults with obesity. Aetna often covers Zepbound for weight loss, but some Aetna plans require prior authorization and that you meet certain eligibility criteria. Aetna coverage for Zepbound for weight loss 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.

Wegovy (semaglutide)

Wegovy is a GLP-1 receptor agonist indicated for chronic weight management in adults and pediatric patients (12 years and older) with obesity, or overweight adults with at least one weight-related condition. It is also indicated to reduce the risk of major adverse cardiovascular events in adults with established cardiovascular disease and either obesity or overweight. Aetna may cover Wegovy when used in conjunction with a reduced-calorie diet and increased physical activity, provided the patient meets specific BMI and comorbidity criteria.

Saxenda (liraglutide)

Saxenda is another GLP-1 receptor agonist approved for chronic weight management. Aetna may cover Saxenda for adults and pediatric patients (12 years and older) who meet specific BMI, weight, and comorbidity criteria.

Qsymia (phentermine/topiramate)

Qsymia is a combination medication containing phentermine and topiramate, indicated for chronic weight management. Aetna may cover Qsymia for adults and pediatric patients (12 years and older) who meet specific BMI and comorbidity criteria.

Contrave (naltrexone/bupropion)

Contrave is a combination medication containing naltrexone and bupropion, indicated for chronic weight management. Aetna may cover Contrave for adults who meet specific BMI and comorbidity criteria.

Xenical (orlistat)

Xenical is a lipase inhibitor that reduces the absorption of dietary fat. Aetna may cover Xenical for obese patients with a 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.

Short-Term Medications (Phentermine, etc.)

Adipex-P (phentermine), Lomaira (phentermine), Phentermine are indicated as a short-term (a few weeks) adjunct in a regimen of weight reduction. Aetna may cover these medications when the patient has NOT received 3 months of therapy or more with the requested drug in the past 365 days.

Understanding Aetna's Clinical Policy Bulletins (CPBs)

Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider.

While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental, investigational, unproven, or cosmetic. Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).

Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in the Clinical Policy Bulletins (CPBs). The discussion, analysis, conclusions and positions reflected in the Clinical Policy Bulletins (CPBs), including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna's opinion and are made without any intent to defame. Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error.

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