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Aetna · Weight Loss

Aetna coverage for Wegovy (Weight Loss)

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

All Wegovy policies under Aetna · Check your card