Aetna Prior Authorization Wegovy: Coverage, Criteria and Costs

Aetna covers Wegovy for eligible members with a diagnosis of obesity or overweight with at least one weight-related condition.

Aetna requires prior authorization for Wegovy, which means you'll need to get approval from your insurance provider before starting treatment.

To get approved for Wegovy, you'll need to meet specific criteria, including having a BMI of 30 or higher, or a BMI of 27 or higher with one or more weight-related conditions.

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To get your Aetna prior authorization for Wegovy approved, it's essential to understand the requirements in advance. You can call Aetna and share your Member ID to ask about their prior authorization criteria for Wegovy.

Aetna, like other insurance providers, requires prior authorization for Wegovy coverage. This involves sharing specific information, such as clinical criteria demonstrating your medical necessity for Wegovy.

To prepare for your call, it's a good idea to have the following information ready: your Member ID, a list of weight loss medications you've tried before Wegovy, and proof that you'll use Wegovy as an adjunct to diet and exercise.

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Here are the common prior authorization criteria for Wegovy, which may be requested by Aetna:

Wegovy is a prescription medicine used with a reduced calorie diet and increased physical activity to reduce the risk of major cardiovascular events and help adults with obesity or overweight lose excess body weight.

It contains semaglutide and should not be used with other semaglutide-containing products or other GLP-1 receptor agonist medicines.

Wegovy comes in five different dosing strengths, ranging from 0.25 mg to 2.4 mg, and the initial prescribed dose is 0.25 mg, which is injected once weekly for 4 weeks.

The standard maintenance doses for Wegovy are 1.7 mg and 2.4 mg, and 3-month prescriptions can be written for both doses.

You can call the Wegovy Navigation Line at 1-833-4-WEGOVY (1-833-493-4689) between 9:00 AM and 6:00 PM ET, Monday–Friday, for more information and support.

Here are the different dosing strengths of Wegovy:

To get your Aetna prior authorization for Wegovy approved, you'll need to provide clinical criteria demonstrating your medical necessity for the medication. This means showing that Wegovy is the right choice for your specific health needs.

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The clinical criteria for Wegovy prior authorization typically include a section for 'Clinical Criteria', which might also be referred to as Diagnosis or Medical Information. This information is crucial in proving that you meet the medical necessity requirements for Wegovy.

A common requirement is to show that you've tried weight loss medications before Wegovy, also known as step therapy. This helps ensure that you've explored other options before moving on to more specialized treatments like Wegovy.

To meet this requirement, you'll need to provide proof that you've tried weight loss medications in the past. This might involve sharing documentation from your doctor or previous treatment records.

The standard information requested for clinical criteria includes your diagnosis, medical history, and current treatment plan. This helps Aetna understand your overall health and why Wegovy is necessary for your care.

Here are some common categories of information requested for clinical criteria:

If your Aetna plan doesn't cover Wegovy, you can still get weight loss medication. You may want to ask your healthcare provider about alternatives to Wegovy, such as compounded semaglutide, which is allowed under federal law for various reasons, including during medication shortages.

Compounded semaglutide is offered by companies like Ro, and it's worth exploring if you qualify. You can also ask your benefits administrator for help getting insurance coverage for Wegovy.

Insurance may deny prior authorization for Wegovy if you haven't tried cheaper medication options first, which is a policy commonly referred to as 'step therapy'. You should report any weight loss medications you have tried prior, such as Contrave, Qsymia, Phentermine, Orlistat, or Saxenda.

If Wegovy is not on your plan's medication list, you can specifically ask for a "formulary exception" within your appeal. Your plan may have "preferred" GLP-1s that they request you take instead of Wegovy, such as Saxenda.

If your insurance thinks you don't meet the medical requirements for Wegovy, they will argue that approving coverage is not "medically necessary". You can detail why your medical history makes Wegovy necessary within your appeal.

Your plan may not cover weight loss medications as a category, which can lead to a denial. You can appeal even if this is your insurance's official policy, focusing on how covering Wegovy now will save your insurance plan later.

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If your plan doesn't cover Wegovy, ask for a list of covered alternatives and share it with your healthcare provider. They can help you determine if there's one worth trying.

You can still get Wegovy for weight loss even if your insurance company denies you coverage. A 1-month supply of Wegovy injection pens retails for around $1,430, but you may be eligible to get Wegovy for free, or at least less, with Novo Nordisk's Wegovy Savings Card.

Here are some ways to save on Wegovy without insurance:

Aetna typically requires prior authorization for Wegovy, which involves your healthcare provider submitting a form demonstrating that Wegovy is a medically necessary treatment option for you.

The specific process for prior authorization can vary by insurance plan, but it usually requires your healthcare provider to submit a form with certain information.

You'll need to meet specific criteria to qualify for coverage, which differ depending on whether you're an adult or a child.

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Here are the general requirements:

It's also possible that Aetna could cover Wegovy for weight loss if you have heart disease, as some plans started covering it for this purpose in April 2024.

To get your prior authorization approved, it's essential to understand the specific requirements for your insurance plan and pharmacy benefits manager (PBM).

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If your Aetna insurance denied prior authorization for Wegovy, you have the right to appeal. A study found that 69% of people who were denied coverage didn't know they could appeal.

Appeals work, with a success rate of 39-59% when patients appeal directly to their insurance provider. This is because denials are often issued by mistake, made by a computer that doesn't consider your personal health situation.

A computer almost always makes the initial decision to deny medication coverage, which can lead to incorrect denials. When you appeal, your information is reviewed by a real person, like a doctor.

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Doctors review appeals, not computers, which makes submitting an appeal a powerful process for overturning denials. You deserve the best care, and appealing can help you get the treatment you need.

Most states have 3 levels of appeals, starting with a phone call to your insurance company to ask for reconsideration. Your healthcare provider can do this for you, and may need to submit additional medical information as evidence.

If the denial persists, the appeal goes to the second level, review by a medical director at your insurance company. The goal is to prove your request should be accepted within your plan's coverage guidelines.

If you're denied prior authorization, don't worry - there are things you can do to get the decision overturned. You can detail why your medical history makes Wegovy necessary within your appeal, especially if your insurance thinks you don't meet the medical requirements.

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If Aetna denies your prior authorization for Wegovy, your healthcare provider can submit an appeal. Novo Nordisk offers a sample letter that can be used for this purpose.

You can save on Wegovy if Aetna won't cover it by using the Wegovy Savings Offer, which can bring the cost down to $650 for a 28-day supply. This savings card can be used for up to 13 refills.

A 1-month supply of Wegovy injection pens retails for around $1,430, but you may be able to get it for free or at a lower cost through Novo Nordisk's Patient Assistance Program (PAP) or by using coupons from prescription discount websites like GoodRx or Optum Perks.

Here are some options to save on Wegovy:

Managing costs for Wegovy and Ozempic can be a challenge. You can start by checking your insurance coverage through Aetna's website or by calling their Member Services number on the back of your insurance card.

To get the best price, consider using a mail-order pharmacy or getting a longer, 90-day prescription. Novo Nordisk's NovoCare online tool can also help you estimate your out-of-pocket costs.

If your plan doesn't cover Wegovy or Ozempic, you can ask for a list of covered alternatives and share it with your healthcare provider. They can help you determine if there's a suitable alternative medication.

A study from the US Government Accountability Office found that 39-59% of internal insurance appeals were successful. This means that an effective appeal can help get your denial overturned.

Here are some steps to take if your insurance plan denies prior authorization for Wegovy or Ozempic:

Note: If your plan doesn't cover Wegovy, you can specifically ask for a "formulary exception" within your appeal.

Insurance companies may deny coverage for Wegovy if it's not on their formulary, which is a list of medications they cover. This means Wegovy isn't one of the preferred GLP-1s they recommend instead, such as Saxenda.

If your plan doesn't cover Wegovy, you can ask for a list of covered alternatives and share it with your healthcare provider. They can help you determine if there's one worth trying.

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Insurance plans may automatically deny coverage for weight loss medications, including Wegovy, as a category. However, you can still appeal this decision and argue that covering Wegovy will save your insurance plan money in the long run.

If your insurance thinks you don't meet the medical requirements for Wegovy, such as the BMI or health condition criteria, they may deny coverage. This can be resolved by detailing why your medical history makes Wegovy necessary within your appeal.

Insurance companies may also deny coverage if they have doubts about the medical necessity of Wegovy in your case. This can be due to a lack of a concurrent medical issue, such as type 2 diabetes, or not meeting approved BMI criteria.

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Insurance companies often try to conserve funds while helping as many people as possible get the treatment they need. They may deny more expensive options in favor of lower-cost alternatives, especially if you haven't tried and failed a low-cost medication before requesting approval for the pricier option.

If your insurance company denies coverage for a medication, there are still ways to save on the cost. For example, websites like GoodRx, SingleCare, and Optum Perks offer prescription discount cards for several pharmacies.

A Flexible Savings Account (FSA) or Health Savings Account (HSA) can also be used to apply funds towards the cost of refilling your prescription. This can be a helpful option for those who have already set aside money for medical expenses.

Novo Nordisk's Wegovy Savings Card can help reduce the cost of Wegovy, a medication used for weight loss. The amount of savings depends on whether you have insurance coverage or pay cash for your prescriptions.

Here are some ways to save on Wegovy without insurance coverage:

Remember, it's essential to talk to your healthcare provider and benefits administrator to understand your options and find the best solution for your specific situation.