Aetna

Does Aetna cover Wegovy?

Quick answer · Weight Loss

Aetna covers Wegovy for weight loss with prior authorization on Employer / Commercial Insurance and ACA Marketplace.

  • Employer / Commercial Insurance: Covered with requirements. BMI of 35 or higher
  • ACA Marketplace: Covered with requirements. BMI of 35 or higher

Last verified June 2, 2026. Policy effective April 10, 2026. Source: policy-260.html. How we verify this data →

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Wegovy for Weight Loss

What Aetna requires, by plan type. Open this indication on its own page →

Employer / Commercial Insurance

Covered with requirements

What you need to qualify

  • Age 18 and older
  • BMI of 35 or higher
  • 6 months of a documented diet and exercise program

Qualification pathways

You can qualify through any one of these.

Adult weight loss - initial approval

All of:

  • Age 18 years or older
  • Baseline BMI >= 35 kg/m2
  • Participated in comprehensive weight management program (behavioral modification, reduced-calorie diet, increased physical activity) with continuing follow-up for at least 6 months prior to drug therapy
  • Used with reduced-calorie diet AND increased physical activity
  • Request is NOT for Wegovy HD 7.2 mg injection OR Wegovy tablets (injection only for adult weight loss criteria)

Documentation to bring

  • Baseline BMI documentation (>= 35 kg/m2)
  • Documentation of participation in a comprehensive weight management program for at least 6 months prior to drug therapy

Quantity limits

  • 0.25 mg/0.5 mL, 0.5 mg/0.5 mL, 1 mg/0.5 mL — 2 mL (1 package of 4 pens) / 21 days; 6 mL (3 packages of 4 pens each) / 63 days (84-day)
  • 1.7 mg/0.75 mL, 2.4 mg/0.75 mL — 3 mL (1 package of 4 pens) / 21 days; 9 mL (3 packages of 4 pens each) / 63 days (84-day)

Approval and renewal

  • Initial approval: 8 months
  • Renewal: every 12 months
  • To renew, the plan looks for at least 5% weight loss from the starting weight, Patient must have completed at least 3 months of therapy at a stable maintenance dose AND lost at least 5% of baseline body weight OR maintained initial 5% weight loss. Baseline BMI >= 35 is re-verified at continuation, and at least 12 weeks on therapy before the first renewal. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

  • Wegovy HD 7.2 mg injection is excluded from adult weight loss criteria under this policy section (has its own separate criteria)
  • Wegovy tablets are excluded from this specific adult weight loss injection criteria section (tablets have separate DOA)

Policy note: This policy is specifically titled 'BMI 35' and requires a baseline BMI >= 35 kg/m2 for adult weight loss (higher than the FDA label threshold of >= 27 with comorbidity or >= 30). Wegovy HD 7.2 mg injection has a separate DOA entry (Initial: 8 months, Continuation: 12 months) but its criteria are not separately detailed — it appears to follow the same adult weight loss criteria. Wegovy tablets have an Initial DOA of 6 months and Continuation DOA of 12 months. Concomitant use with other semaglutide-containing products or other GLP-1 receptor agonists is not recommended.

Policy effective April 10, 2026 · verified June 2, 2026 · source: policy-260.html

ACA Marketplace

Covered with requirements

What you need to qualify

  • Age 18 and older
  • BMI of 35 or higher
  • 6 months of a documented diet and exercise program

Qualification pathways

You can qualify through any one of these.

Adult weight loss - initial approval

All of:

  • Age 18 years or older
  • Baseline BMI >= 35 kg/m2
  • Participated in comprehensive weight management program (behavioral modification, reduced-calorie diet, increased physical activity) with continuing follow-up for at least 6 months prior to drug therapy
  • Used with reduced-calorie diet AND increased physical activity
  • Request is NOT for Wegovy HD 7.2 mg injection OR Wegovy tablets (injection only for adult weight loss criteria)

Documentation to bring

  • Baseline BMI documentation (>= 35 kg/m2)
  • Documentation of participation in a comprehensive weight management program for at least 6 months prior to drug therapy

Quantity limits

  • 0.25 mg/0.5 mL, 0.5 mg/0.5 mL, 1 mg/0.5 mL — 2 mL (1 package of 4 pens) / 21 days; 6 mL (3 packages of 4 pens each) / 63 days (84-day)
  • 1.7 mg/0.75 mL, 2.4 mg/0.75 mL — 3 mL (1 package of 4 pens) / 21 days; 9 mL (3 packages of 4 pens each) / 63 days (84-day)

Approval and renewal

  • Initial approval: 8 months
  • Renewal: every 12 months
  • To renew, the plan looks for at least 5% weight loss from the starting weight, Patient must have completed at least 3 months of therapy at a stable maintenance dose AND lost at least 5% of baseline body weight OR maintained initial 5% weight loss. Baseline BMI >= 35 is re-verified at continuation, and at least 12 weeks on therapy before the first renewal. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

  • Wegovy HD 7.2 mg injection is excluded from adult weight loss criteria under this policy section (has its own separate criteria)
  • Wegovy tablets are excluded from this specific adult weight loss injection criteria section (tablets have separate DOA)

Policy note: This policy is specifically titled 'BMI 35' and requires a baseline BMI >= 35 kg/m2 for adult weight loss (higher than the FDA label threshold of >= 27 with comorbidity or >= 30). Wegovy HD 7.2 mg injection has a separate DOA entry (Initial: 8 months, Continuation: 12 months) but its criteria are not separately detailed — it appears to follow the same adult weight loss criteria. Wegovy tablets have an Initial DOA of 6 months and Continuation DOA of 12 months. Concomitant use with other semaglutide-containing products or other GLP-1 receptor agonists is not recommended.

Policy effective April 10, 2026 · verified June 2, 2026 · source: policy-260.html

Wegovy for Heart Disease Risk Reduction

What Aetna requires, by plan type. Open this indication on its own page →

Employer / Commercial Insurance

Covered with requirements

What you need to qualify

  • Age 18 and older
  • BMI of 27 or higher
  • Established cardiovascular disease (MI, stroke, PAD, and coronary_revascularization)
  • On guideline-directed medical therapy (lipid-lowering agent, antiplatelet, beta_blocker, and renin-angiotensin inhibitor)
  • Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

CV risk reduction - initial approval (Wegovy injection only, not HD)

All of:

  • Request is for Wegovy (semaglutide) injection — NOT Wegovy HD 7.2 mg injection
  • Used with reduced-calorie diet AND increased physical activity
  • Patient does NOT have type 2 diabetes
  • Baseline BMI >= 27 kg/m2
  • Currently receiving GDMT for CVD OR has clinical reason not to receive GDMT

Plus any one of:

  • Previous MI
  • Previous stroke
  • Symptomatic PAD with ABI < 0.85 at rest, peripheral arterial revascularization, or amputation due to atherosclerotic disease
  • Prior history of revascularization (CABG, PCI, or angioplasty)

Documentation to bring

  • Documentation of qualifying CVD event (MI, stroke, PAD with ABI < 0.85/revascularization/amputation, or prior CABG/PCI/angioplasty)
  • Baseline BMI documentation (>= 27 kg/m2)
  • Documentation of current GDMT use (lipid-lowering agent, antiplatelet, beta-blocker, renin-angiotensin inhibitor) OR clinical reason GDMT is not appropriate
  • Documentation confirming patient does NOT have type 2 diabetes

Quantity limits

  • 0.25 mg/0.5 mL, 0.5 mg/0.5 mL, 1 mg/0.5 mL — 2 mL (1 package of 4 pens) / 21 days; 6 mL (3 packages of 4 pens each) / 63 days (84-day)
  • 1.7 mg/0.75 mL, 2.4 mg/0.75 mL — 3 mL (1 package of 4 pens) / 21 days; 9 mL (3 packages of 4 pens each) / 63 days (84-day)

Approval and renewal

  • Initial approval: 12 months
  • Renewal: every 12 months
  • To renew, the plan looks for Continuation requires: established CVD history (one of MI, stroke, PAD, revascularization) re-verified; patient being treated with maintenance dosage based on individual treatment response and tolerability. T2DM exclusion and GDMT requirement are NOT re-verified at continuation per the continuation criteria section.

Not covered when

  • Type 2 diabetes patients are excluded (directed to Ozempic instead)
  • Wegovy HD 7.2 mg injection is excluded from CV risk reduction coverage
  • Wegovy tablets have a separate CV risk reduction DOA of 12 months but criteria are not separately detailed in the document

Policy note: Policy explicitly states patients with T2DM may be treated for CV risk reduction with Ozempic instead. Wegovy tablets are also approved for CV risk reduction per FDA and listed in DOA section (12 months) but the detailed criteria section specifies 'Wegovy ONLY (EXCLUDING Wegovy HD 7.2 mg Injection)' without separately calling out tablets — tablets appear to fall under same CV criteria. GDMT examples listed: lipid-lowering agent, antiplatelet, beta-blocker, renin-angiotensin inhibitor.

Policy effective April 10, 2026 · verified June 2, 2026 · source: policy-260.html

ACA Marketplace

Covered with requirements

What you need to qualify

  • Age 18 and older
  • BMI of 27 or higher
  • Established cardiovascular disease (MI, stroke, PAD, and coronary_revascularization)
  • On guideline-directed medical therapy (lipid-lowering agent, antiplatelet, beta_blocker, and renin-angiotensin inhibitor)
  • Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

CV risk reduction - initial approval (Wegovy injection only, not HD)

All of:

  • Request is for Wegovy (semaglutide) injection — NOT Wegovy HD 7.2 mg injection
  • Used with reduced-calorie diet AND increased physical activity
  • Patient does NOT have type 2 diabetes
  • Baseline BMI >= 27 kg/m2
  • Currently receiving GDMT for CVD OR has clinical reason not to receive GDMT

Plus any one of:

  • Previous MI
  • Previous stroke
  • Symptomatic PAD with ABI < 0.85 at rest, peripheral arterial revascularization, or amputation due to atherosclerotic disease
  • Prior history of revascularization (CABG, PCI, or angioplasty)

Documentation to bring

  • Documentation of qualifying CVD event (MI, stroke, PAD with ABI < 0.85/revascularization/amputation, or prior CABG/PCI/angioplasty)
  • Baseline BMI documentation (>= 27 kg/m2)
  • Documentation of current GDMT use (lipid-lowering agent, antiplatelet, beta-blocker, renin-angiotensin inhibitor) OR clinical reason GDMT is not appropriate
  • Documentation confirming patient does NOT have type 2 diabetes

Quantity limits

  • 0.25 mg/0.5 mL, 0.5 mg/0.5 mL, 1 mg/0.5 mL — 2 mL (1 package of 4 pens) / 21 days; 6 mL (3 packages of 4 pens each) / 63 days (84-day)
  • 1.7 mg/0.75 mL, 2.4 mg/0.75 mL — 3 mL (1 package of 4 pens) / 21 days; 9 mL (3 packages of 4 pens each) / 63 days (84-day)

Approval and renewal

  • Initial approval: 12 months
  • Renewal: every 12 months
  • To renew, the plan looks for Continuation requires: established CVD history (one of MI, stroke, PAD, revascularization) re-verified; patient being treated with maintenance dosage based on individual treatment response and tolerability. T2DM exclusion and GDMT requirement are NOT re-verified at continuation per the continuation criteria section.

Not covered when

  • Type 2 diabetes patients are excluded (directed to Ozempic instead)
  • Wegovy HD 7.2 mg injection is excluded from CV risk reduction coverage
  • Wegovy tablets have a separate CV risk reduction DOA of 12 months but criteria are not separately detailed in the document

Policy note: Policy explicitly states patients with T2DM may be treated for CV risk reduction with Ozempic instead. Wegovy tablets are also approved for CV risk reduction per FDA and listed in DOA section (12 months) but the detailed criteria section specifies 'Wegovy ONLY (EXCLUDING Wegovy HD 7.2 mg Injection)' without separately calling out tablets — tablets appear to fall under same CV criteria. GDMT examples listed: lipid-lowering agent, antiplatelet, beta-blocker, renin-angiotensin inhibitor.

Policy effective April 10, 2026 · verified June 2, 2026 · source: policy-260.html

Wegovy for Liver Disease (MASH)

What Aetna requires, by plan type. Open this indication on its own page →

Employer / Commercial Insurance

Covered with requirements

What you need to qualify

  • Age 18 and older
  • Prescribed by or in consultation with a specialist
  • Confirmed MASH diagnosis by FibroScan_VCTE, MRE, and liver_biopsy, fibrosis stage F2 to F3

Qualification pathways

You can qualify through any one of these.

Noncirrhotic MASH with moderate to advanced fibrosis (F2-F3) - initial approval

All of:

  • Request is for Wegovy (semaglutide) injection — NOT Wegovy HD 7.2 mg injection OR Wegovy tablets
  • Used with reduced-calorie diet AND increased physical activity
  • Prescribed by or in consultation with a gastroenterologist or hepatologist
  • Noncirrhotic MASH diagnosis
  • Moderate to advanced liver fibrosis (stages F2 to F3) confirmed by non-invasive liver disease assessment (e.g., ultrasound-based elastography, MRE) OR historical liver biopsy

Documentation to bring

  • Documentation of noncirrhotic MASH diagnosis with moderate to advanced liver fibrosis (F2-F3)
  • Non-invasive liver disease assessment results (e.g., ultrasound-based elastography, MRE) OR historical liver biopsy confirming F2-F3 fibrosis
  • Documentation of prescribing or consulting gastroenterologist or hepatologist

Quantity limits

  • 0.25 mg/0.5 mL, 0.5 mg/0.5 mL, 1 mg/0.5 mL — 2 mL (1 package of 4 pens) / 21 days; 6 mL (3 packages of 4 pens each) / 63 days (84-day)
  • 1.7 mg/0.75 mL, 2.4 mg/0.75 mL — 3 mL (1 package of 4 pens) / 21 days; 9 mL (3 packages of 4 pens each) / 63 days (84-day)

Approval and renewal

  • Initial approval: 12 months
  • Renewal: every 12 months
  • To renew, the plan looks for Positive clinical response required: improvement in liver function such as reduction in ALT, improvement in Enhanced Liver Fibrosis (ELF) score, improvement in liver stiffness measurement (LSM) by ultrasound-based elastography or MRE. Patient must be treated with maintenance dosage based on individual treatment response and tolerability.

Not covered when

  • Wegovy HD 7.2 mg injection is excluded from MASH coverage
  • Wegovy tablets are excluded from MASH coverage
  • Cirrhotic MASH is excluded (noncirrhotic only)

Policy note: MASH indication approved under FDA accelerated approval. Policy specifies confirmation methods as non-invasive liver disease assessment (e.g., ultrasound-based elastography, MRE) OR historical liver biopsy — no specific lookback period stated. Specialist (gastroenterologist or hepatologist) required at initial approval. Continuation does not re-require specialist attestation per the continuation criteria text. DOA is 12 months for both initial and continuation.

Policy effective April 10, 2026 · verified June 2, 2026 · source: policy-260.html

ACA Marketplace

Covered with requirements

What you need to qualify

  • Age 18 and older
  • Prescribed by or in consultation with a specialist
  • Confirmed MASH diagnosis by FibroScan_VCTE, MRE, and liver_biopsy, fibrosis stage F2 to F3

Qualification pathways

You can qualify through any one of these.

Noncirrhotic MASH with moderate to advanced fibrosis (F2-F3) - initial approval

All of:

  • Request is for Wegovy (semaglutide) injection — NOT Wegovy HD 7.2 mg injection OR Wegovy tablets
  • Used with reduced-calorie diet AND increased physical activity
  • Prescribed by or in consultation with a gastroenterologist or hepatologist
  • Noncirrhotic MASH diagnosis
  • Moderate to advanced liver fibrosis (stages F2 to F3) confirmed by non-invasive liver disease assessment (e.g., ultrasound-based elastography, MRE) OR historical liver biopsy

Documentation to bring

  • Documentation of noncirrhotic MASH diagnosis with moderate to advanced liver fibrosis (F2-F3)
  • Non-invasive liver disease assessment results (e.g., ultrasound-based elastography, MRE) OR historical liver biopsy confirming F2-F3 fibrosis
  • Documentation of prescribing or consulting gastroenterologist or hepatologist

Quantity limits

  • 0.25 mg/0.5 mL, 0.5 mg/0.5 mL, 1 mg/0.5 mL — 2 mL (1 package of 4 pens) / 21 days; 6 mL (3 packages of 4 pens each) / 63 days (84-day)
  • 1.7 mg/0.75 mL, 2.4 mg/0.75 mL — 3 mL (1 package of 4 pens) / 21 days; 9 mL (3 packages of 4 pens each) / 63 days (84-day)

Approval and renewal

  • Initial approval: 12 months
  • Renewal: every 12 months
  • To renew, the plan looks for Positive clinical response required: improvement in liver function such as reduction in ALT, improvement in Enhanced Liver Fibrosis (ELF) score, improvement in liver stiffness measurement (LSM) by ultrasound-based elastography or MRE. Patient must be treated with maintenance dosage based on individual treatment response and tolerability.

Not covered when

  • Wegovy HD 7.2 mg injection is excluded from MASH coverage
  • Wegovy tablets are excluded from MASH coverage
  • Cirrhotic MASH is excluded (noncirrhotic only)

Policy note: MASH indication approved under FDA accelerated approval. Policy specifies confirmation methods as non-invasive liver disease assessment (e.g., ultrasound-based elastography, MRE) OR historical liver biopsy — no specific lookback period stated. Specialist (gastroenterologist or hepatologist) required at initial approval. Continuation does not re-require specialist attestation per the continuation criteria text. DOA is 12 months for both initial and continuation.

Policy effective April 10, 2026 · verified June 2, 2026 · source: policy-260.html

Why Wegovy requests get denied by Aetna

Based on what this policy asks for. Fix these before the first submission.

  1. Wrong brand for the diagnosis. Wegovy and Ozempic are the same molecule with different approved uses; a request for Wegovy under a diagnosis that matches Ozempic is routinely denied.
  2. BMI not documented in the chart notes (or documented without a baseline weight and date).
  3. No documented diet and exercise program.
  4. Prescriber isn't the specialist the plan requires.
  5. Baseline weight wasn't recorded at the start, so the required weight loss can't be shown at renewal.

Frequently asked questions

Does Aetna cover Wegovy?
Aetna covers Wegovy for weight loss with prior authorization on Employer / Commercial Insurance and ACA Marketplace.
What BMI do you need for Wegovy under Aetna?
For weight loss on Employer / Commercial Insurance plans, Aetna requires a BMI of 35 or higher. Other plan types may differ — see each plan type below.
How long does a Wegovy approval last with Aetna?
Initial approvals last 8 months, and renewals are granted in 12-month periods.
What does Aetna require to renew Wegovy?
At least 5% weight loss from the starting weight, Patient must have completed at least 3 months of therapy at a stable maintenance dose AND lost at least 5% of baseline body weight OR maintained initial 5% weight loss. Baseline BMI >= 35 is re-verified at continuation, and at least 12 weeks on therapy before the first renewal.
How current is this information?
This page reflects Aetna's written policy as of April 10, 2026, last verified against the source document on June 2, 2026.

Other medications under Aetna

Wegovy coverage under other plans

All insurance plans · All medications

This page summarizes Aetna's written prior-authorization policy. It is not a guarantee of coverage; plans vary by employer and benefit design. Verify with your plan before relying on it.