Aetna Mounjaro Prior Authorization Process and Coverage

Aetna requires prior authorization for Mounjaro, a medication used to treat type 2 diabetes.

To initiate the prior authorization process, patients or healthcare providers must submit a request to Aetna, which typically involves providing medical records and documentation.

This process can take up to 5 days, but it's essential to note that Aetna may request additional information or clarification, which can delay the process.

Aetna covers Mounjaro for patients with type 2 diabetes, but coverage may vary depending on individual circumstances and plan details.

To check if your Aetna plan covers Ozempic, you can call the Member Services number on the back of your insurance card, or contact Aetna via email or chat.

You can also review your plan's drug formulary, which includes a list of the drugs covered by your plan. To find your formulary, visit the Aetna website and select the current year and your plan.

Novo Nordisk offers a free online tool called NovoCare that allows you to check your insurance coverage. Fill in your information, and the tool will share your plan's coverage of Ozempic, including your estimated out-of-pocket costs.

If Aetna won't cover Ozempic, you can ask your healthcare provider to submit an appeal. Alternatively, your insurance plan may cover an alternative medication, such as Mounjaro or Rybelsus.

If you have a Flexible Savings Account (FSA) or Health Savings Account (HSA), you may be able to apply those funds towards Ozempic.

If Aetna won't cover Ozempic, you can ask your healthcare provider to submit an appeal. Sometimes, insurance plans deny prior authorization requests.

Your healthcare provider can also review your prescription drug coverage and suggest an alternative medication if Ozempic isn't covered. For example, some insurance plans may cover Mounjaro (tirzepatide) or Rybelsus (semaglutide) instead.

You should talk to your healthcare provider and benefits administrator to understand your options. They can help you figure out if one of these alternatives could be a good fit for you.

Mounjaro has serious warnings and safety information that you should be aware of.

If you're considering using Wegovy with an Aetna plan, there are specific criteria you'll need to meet. Aetna follows FDA-approved indications for Wegovy prescriptions, which means adults must take the drug in conjunction with a reduced-calorie diet and increased physical activity for chronic weight management.

To be eligible for coverage, adults with an Aetna plan must have a body mass index (BMI) of 30 or higher, or a BMI of 27 or higher with at least one weight-related comorbid condition, such as high blood pressure or diabetes.

Insurance companies, including Aetna, may cover Wegovy with no restrictions or require prior authorization to ensure the treatment is medically necessary. Prior authorization criteria vary and typically occurs between the prescribing healthcare provider and the insurance company.

Aetna plans will cover Wegovy with prior authorization for adults ages 18 and older if they've either completed at least three months of Wegovy at a stable maintenance dose and lost 5% of their baseline body weight, or participated in a comprehensive weight management program for at least six months prior to using drug therapy.

To determine your eligibility, contact your plan administrator for details, as insurance coverage and cost for Wegovy vary by Aetna plan.

Aetna's coverage of Mounjaro can be complex, but here's what you need to know.

Aetna may or may not cover Mounjaro, and coverage can depend on your plan's prescription drug coverage and the reason you're taking it.

Mounjaro is typically covered by Aetna, but prior authorization is usually required, especially if you don't have diabetes.

Some plans may also require that other diabetes medications be tried first before starting Mounjaro.

Aetna's coverage of Mounjaro can vary depending on the specific plan, with some plans covering it and others not.

The cost of Mounjaro can be high, reaching almost $1,000 for a month's supply of the medication.

Here are some specific plans that we know cover Mounjaro: Aetna's Advanced Control Plan and the Aetna Standard Plan.

These plans cover Mounjaro as a Preferred Brand drug, which has a higher copay than Aetna's Preferred Generics drug tier.