Obesity is a serious global health concern, increasing the risk of other diseases. Aetna offers resources to help members manage their weight, but coverage for specific weight loss treatments can vary. This article explores the details of Aetna's weight loss program, including coverage policies, approved medications, and additional support resources.
General Coverage Policies
Many Aetna plans have specific exclusions regarding services and supplies related to obesity treatment, diet, or weight control. Under these plans, weight reduction medications and physician supervision of weight reduction programs may be denied. However, Aetna may consider up to 26 individual or group visits with a recognized provider per year as medically necessary for weight reduction counseling for obese adults (BMI ≥ 30 kg/m2). It’s important to note that even if the plan covers weight loss treatments, weight reduction medications may be specifically excluded under the pharmacy benefit or the health benefits plan. The medical necessity criteria may not apply to plans with these specific exclusions.
Weight Reduction Medications
When weight reduction medications are covered, they are intended to be used alongside caloric restriction, exercise, and behavioral modification. Weight loss from medication is often temporary, and there is a potential for physical dependence and addiction. An exception is made for individuals who cannot maintain weight loss through behavioral therapy and are at risk of medical complications from obesity. In such cases, the risks of continued obesity may outweigh the risks of dependence or adverse effects from medication.
It's important to monitor the effectiveness of weight loss drugs early in treatment. If a person does not lose 4.4 lbs (2 kg) within the first four weeks of therapy, long-term response is unlikely.
FDA-Approved Medications Covered by Aetna
Aetna's coverage for weight loss medications aligns with FDA-approved indications:
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- Adipex-P (phentermine), Lomaira (phentermine), Phentermine: These are approved for short-term use alongside exercise, behavioral modification, and caloric restriction for managing exogenous obesity in patients with a BMI ≥ 30 kg/m2, or ≥ 27 kg/m2 with other risk factors like controlled hypertension, diabetes, or hyperlipidemia.
- Benzphetamine: Indicated for short-term use as part of a weight reduction regimen based on caloric restriction for patients with a BMI of 30 kg/m2 or higher who haven't responded to diet and exercise alone. It is for monotherapy only.
- Contrave (naltrexone/bupropion extended-release): This is an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with a BMI ≥ 30 kg/m2, or ≥ 27 kg/m2 with at least one weight-related comorbidity.
- Diethylpropion: For short-term use alongside caloric restriction in patients with a BMI ≥ 30 kg/m2 who haven't responded to diet and exercise alone. It is for monotherapy only.
- Phendimetrazine: This is a short-term adjunct to a weight reduction regimen based on caloric restriction for patients with a BMI ≥ 30 kg/m2, or ≥ 27 kg/m2 with other risk factors. It is for monotherapy only.
- Qsymia (phentermine/topiramate extended-release): Indicated alongside a reduced-calorie diet and increased physical activity for chronic weight management in adults with a BMI ≥ 30 kg/m2, or ≥ 27 kg/m2 with at least one weight-related comorbidity, and in pediatric patients aged 12 years and older with a BMI in the 95th percentile or greater.
- Saxenda (liraglutide): This is an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with a BMI ≥ 30 kg/m2, or ≥ 27 kg/m2 with at least one weight-related comorbidity, and in pediatric patients aged 12 years and older with a body weight above 60 kg and a BMI corresponding to 30 kg/m2 or greater for adults.
- Wegovy (semaglutide): Indicated alongside a reduced-calorie diet and increased physical activity to reduce the risk of major adverse cardiovascular events in adults with established cardiovascular disease and either obesity or overweight, and to reduce excess body weight and maintain weight reduction long term in adults and pediatric patients aged 12 years and older with obesity or adults with overweight and at least one weight-related comorbidity.
- Xenical (orlistat): For obesity management including weight loss and weight maintenance when used with a reduced-calorie diet. It is also indicated to reduce the risk for weight regain after prior weight loss. It is for obese patients with a BMI ≥ 30 kg/m2 or ≥ 27 kg/m2 with other risk factors.
- Zepbound (tirzepatide): Indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with a 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.
Important Considerations for Specific Medications
- Didrex (benzphetamine hydrochloride): This medication is contraindicated in patients with advanced arteriosclerosis, symptomatic cardiovascular disease, moderate to severe hypertension, hyperthyroidism, known hypersensitivity to sympathomimetic amines, and glaucoma. It should not be given to agitated patients or those with a history of drug abuse. It is also contraindicated in pregnant women.
- Contrave: The effect of Contrave on cardiovascular morbidity and mortality has not been established.
- Qsymia: Qsymia is contraindicated in pregnancy, glaucoma, hyperthyroidism, hypersensitivity to sympathomimetic amines, and within 14 days of taking monoamine oxidase inhibitors.
- Saxenda: Saxenda has a boxed warning about thyroid C-cell tumors in rats and mice. It is contraindicated in patients with a personal or family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Saxenda should not be coadministered with other liraglutide-containing products or with any other GLP-1 receptor agonist.
- Wegovy: Coadministration with other semaglutide-containing products or with any other GLP-1 receptor agonist is not recommended.
- Zepbound: Coadministration with other tirzepatide-containing products or with any glucagon-like peptide-1 (GLP-1) receptor agonist is not recommended. Zepbound has not been studied in patients with a history of pancreatitis.
- Orlistat (Xenical, Alli): Orlistat prevents the breakdown and absorption of fat, leading to its excretion in feces. This can improve comorbidities associated with obesity. Supplementation with fat-soluble vitamins is recommended. Orlistat is contraindicated in persons with chronic malabsorption syndromes and cholestasis.
Withdrawn Medications
- Belviq (lorcaserin): Although initially approved by the FDA, Belviq was later withdrawn from the market due to data from the CAMELLIA-TIMI 61 trial, which showed a numerical imbalance in the number of patients with malignancies compared to placebo.
Aetna Coverage Criteria
Aetna has specific criteria for authorizing weight loss drugs, which differ slightly between adults and children. These criteria are designed to ensure that the medications are used safely and effectively.
Morbid Obesity (Adult)
Authorization may be granted when all of the following criteria are met:
- The patient is actively enrolled in a weight loss program that combines a reduced-calorie diet and increased physical activity.
- The patient's age is appropriate according to FDA labeling of the requested drug.
- The patient is not taking two weight loss drugs simultaneously.
- The patient has no contraindications to the requested drug.
- The requested drug is being used for an FDA-approved indication.
- The patient is 18 years of age or older.
- The patient meets one of the following criteria:
- A documented diagnosis of morbid obesity, defined by a current BMI ≥ 40 kg/m2.
- A documented diagnosis of morbid obesity, defined by a current BMI ≥ 35 kg/m2, AND at least one comorbidity (cardiovascular disease, hypertension, dyslipidemia, diabetes, elevated waist circumference) or another obesity-related medical condition (e.g., sleep apnea).
- If the request is for Adipex-P (phentermine), benzphetamine, diethylpropion, Lomaira (phentermine), phendimetrazine, or phentermine, the patient has not received 3 months or more of therapy with the requested drug in the past 365 days.
Obesity (Pediatric)
Authorization may be granted when all of the following criteria are met:
- The patient is actively enrolled in a weight loss program that combines a reduced-calorie diet and increased physical activity.
- The patient's age is appropriate according to FDA labeling of the requested drug.
- The patient is not taking two weight loss drugs simultaneously.
- The patient has no contraindications to the requested drug.
- The requested drug is being used for an FDA-approved indication.
- The patient is 12 to 17 years of age.
- If the request is for Qsymia (phentermine/topiramate extended-release), the patient has a BMI in the 95th percentile or greater, standardized for age and sex.
- If the request is for Saxenda (liraglutide), the patient has a body weight above 60 kg and a BMI corresponding to 30 kg/m2 or greater for adults (obese) by international cut-offs (Cole Criteria).
- If the request is for Wegovy (semaglutide), the patient has a BMI in the 95th percentile or greater, standardized for age and sex.
Chronic Weight Management (Adult)
Authorization may be granted when the requested drug will be used with a reduced calorie diet and increased physical activity for chronic weight management when ALL of the following criteria are met:
- The patient is 18 years of age or older
- 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
- The patient has a baseline body mass index (BMI) greater than or equal to 35 kg/m2
Chronic Weight Management (Pediatric) - Saxenda and Wegovy ONLY
Authorization may be granted when the requested drug will be used with a reduced calorie diet and increased physical activity for chronic weight management when ALL of the following criteria are met:
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- The patient is 12 to 17 years of age
- 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
- 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)
Authorization may be granted for Wegovy (semaglutide) when prescribed 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, provided that all of the following criteria are met:
- 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), or prior history of revascularization.
- 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 Weight Management Support
Aetna provides additional resources to support members in their weight management journey:
- Weight Loss Programs and Meal Plans: Aetna members have access to discounts on popular weight-loss programs and meal plans.
- Online Health Coaching: The "Simple Steps To A Healthier Life" program offers personalized plans, convenient tools, and online coaching sessions.
- Fitness Discounts: Savings on gym memberships, health coaches, and nutrition products are available.
- Wellness Services: Discounts on massage therapy, acupuncture, chiropractic visits, and nutrition services are included.
- Vision and Hearing Discounts: These benefits are included with Aetna plans.
Lifestyle Interventions
While medications can play a role in weight management, lifestyle interventions are crucial for long-term success.
Very-Low-Energy Diets (VLED)
VLEDs can be safe and effective for up to 3 months under supervised conditions for patients who haven't met their weight loss goals with standard low-fat, reduced-energy approaches. Longer-term studies show significant weight loss and improvements in blood pressure, waist circumference, and lipid profile following a VLED.
Indirect Calorimetry
Using indirect calorimetry to set personalized energy goals can improve the efficacy of weight management programs.
Read also: Aetna Healthy Benefits Guide
Capsaicinoids
Capsaicinoids, found in chili peppers, may help support weight management by reducing energy intake. Studies have shown that capsaicinoid ingestion before a meal can reduce energy intake during the meal.