Does Aetna Cover Wegovy for Weight Loss? Complete Guide

When considering weight loss treatments, people often worry about whether insurance will cover them. Wegovy, a relatively new medication that has shown promise in aiding weight loss, is no exception.

For people covered by Aetna, it is crucial to understand whether this medication is included in their plan. Navigating insurance policies can be complex, and knowing the specifics about coverage for weight loss medications like Wegovy can help patients make informed decisions about their health journey.

In today’s article, we talk about whether Aetna insurance covers Wegovy. We want to help people understand if this weight loss medicine is included in Aetna’s plans, so they can make better choices about their health.

Understanding Wegovy as a Weight Loss Treatment

What is Wegovy?

Wegovy is a relatively new medication in the field of weight loss treatments. Approved by the FDA in June 2021, it has become well-known for helping people lose weight effectively.

It is a prescription medication specifically designed for weight loss in adults who are either overweight or obese. Clinical studies have shown that patients taking Wegovy experienced significant weight loss compared to those following a placebo regimen. The medication is usually used in conjunction with a reduced-calorie diet and increased physical activity for optimal results.

How Wegovy works

Wegovy works by mimicking a hormone called glucagon-like peptide-1 (GLP-1) that targets areas of the brain involved in regulating appetite and food intake.

By activating these receptors, Wegovy helps curb hunger and boost feelings of fullness which helps patients to eat fewer calories. When combined with lifestyle changes like diet and exercise, this can lead to significant and lasting weight loss over time.

Who can be prescribed wegovy?

You may qualify for Wegovy if your Body Mass Index (BMI) is 30kg/m² or higher, and you have at least one weight-related health condition, such as prediabetes or type 2 diabetes.

It is also available for adults with a BMI of 27 or higher who have at least one weight-related condition such as high blood pressure, or high cholesterol. A healthcare professional evaluates factors such as overall health, weight loss history, and potential benefits before prescribing Wegovy to ensure it is the right choice for the patient.

Benefits of Wegovy for Weight Loss

Wegovy has shown promising results in helping people lose weight and maintain a healthier lifestyle. Some of the potential benefits include:

Significant weight loss: Clinical trials have shown that patients taking Wegovy lost an average of 15.2% of their body weight, compared with 2.6% for placebo
Appetite Regulation: Wegovy helps in controlling appetite by mimicking GLP-1, a hormone that reduces hunger and increases feelings of fullness.
Improved Metabolic Health: The medication can lead to better management of weight-related health conditions such as type 2 diabetes and high blood pressure.
Enhanced Quality of Life: Patients often report improvements in self-esteem, physical mobility, and overall quality of life due to weight loss.
Minimal Side Effects: While some patients may experience mild side effects like nausea or diarrhea, these are generally manageable and decrease over time.
Non-Invasive Option: As a medication, Wegovy offers a non-surgical alternative for individuals seeking significant weight loss.
Support for Lifestyle Changes: Wegovy is designed to complement a reduced-calorie diet and increased physical activity, making it a comprehensive approach to weight loss.

Does Aetna Cover Wegovy for Weight Loss?

Yes, Aetna does cover Wegovy for weight loss under certain conditions. Coverage usually depends on the specific Aetna insurance plan you have, as different plans may have different criteria and requirements for covering weight loss medications.

Generally, you will need to meet specific criteria set by Aetna, such as a diagnosis of obesity or a weight-related condition like type 2 diabetes. It is essential to verify coverage directly with Aetna or consult your healthcare provider to ensure you meet the necessary requirements and understand any potential out-of-pocket expenses.

ALSO READ: Does UHC Cover Wegovy for Weight Loss?

Eligibility Criteria for Wegovy Coverage by Aetna

To determine if Wegovy is covered under your specific Aetna insurance plan, it is important to first understand the typical eligibility criteria set by them. Generally, Aetna may require the following conditions to be met for coverage:

Medical Necessity: A physician must determine that Wegovy is medically necessary for the patient’s weight management. This often involves a detailed medical history and assessment.
Body Mass Index (BMI) Requirements: Patients usually need to have a BMI of 30 kg/m² or higher, or a BMI of 27 kg/m² or higher with at least one weight-related condition like type 2 diabetes, high cholesterol, or hypertension.
Stable Maintenance Dose: You should have completed at least three months on a stable maintenance dose of Wegovy and lost 5% of your baseline body weight.
Previous Weight Loss Attempts: Proof of previous unsuccessful weight loss efforts through diet and exercise may be required. Aetna often looks for documented attempts at weight loss programs or medications.
Clinical Documentation: Comprehensive clinical documentation from healthcare providers is essential. This includes records of weight, BMI, coexisting medical conditions, and previous treatments.
Prior Authorization: Prior authorization is often required before the medication is covered. This process involves Aetna reviewing the medical necessity and appropriateness of Wegovy for the patient.
Covered Indications: Aetna usually covers medications like Wegovy for specific indications approved by the FDA. Off-label uses might not be covered.

For the most accurate and reliable information about your coverage, contact Aetna directly. Also, your healthcare provider can give you more personalized advice.

What’s the cost of Wegovy with and without insurance?

The cost of Wegovy can vary significantly based on whether you have insurance and the specifics of your insurance plan. For those with insurance coverage, out-of-pocket expenses generally depend on factors such as co-pay amounts, deductibles, and whether the medication is covered under your plan’s formulary.

Wegovy comes in packs of four pens, each pre-filled with a single dose. Without any insurance, the cost is approximately $1,349.02 per month, which equates to about $269.80 per week or $16,188.24 annually.

Even if you don’t have insurance, you can still save money. Websites like GoodRx give free coupons that you can use at many pharmacies like Walgreens and CVS. You could save between 7-34% off the regular price. Remember, there isn’t a generic version of Wegovy available yet, and it might take a while before one is.

Novo Nordisk, the maker of Wegovy, has a savings program called WeGoTogether to help with costs. If you have private or commercial insurance that covers prescriptions, you could pay as little as $0 for a 28-day supply of Wegovy. If you don’t have insurance for Wegovy, the program can save you up to $500 for a 28-day supply.

Factors that affect the coverage

There are many factors that can affect your insurance coverage and out-of-pocket costs for Wegovy. Some of the most significant ones include:

Insurance Plan Type: Different insurance plans have varying levels of coverage for weight loss medications. Check if Wegovy is included in your specific plan.
Policy Exclusions: Some policies may have exclusions or limitations regarding weight loss treatments. Review your policy to understand what is excluded.
Deductibles and Co-Payments: The amount you need to pay out-of-pocket can depend on your plan’s deductibles and co-payment requirements.
Prior Authorization: Many insurance companies require prior authorization for Wegovy which means your doctor must prove the medication is medically necessary.
Network Pharmacies: Coverage may be better if you use a pharmacy that is within your insurance network.
Coverage Limits: Your insurance plan might have limits on the amount or duration of coverage for weight loss medication.
State Regulations: Some states have specific regulations regarding what weight loss treatments must be covered by insurance.
Benefit Year: Coverage details can change at the start of a new benefit year, so check your policy updates annually.
Employment Status: Changes in your employment can affect your insurance coverage, especially if you switch jobs or insurance providers.

So, these are some main things that can affect your insurance for Wegovy. It’s always good to ask your insurance company and doctor for the most accurate info about if you’re eligible, the costs, and any changes in coverage.

Alternative Weight-Loss Treatments

When we explore alternative weight loss treatments, it is crucial to understand both the efficacy and suitability of various options based on our health profiles and weight management goals. Here are some well-regarded alternatives:

1. Lifestyle Modifications

Making some lifestyle changes, like eating a balanced diet and getting regular exercise, is key to managing your weight. Eating better often means cutting calories, choosing healthy foods, and watching how much you eat. Exercise can be anything from walking, running, and swimming, to strength training to build muscle and boost your metabolism.

2. Pharmacotherapy

In addition to Wegovy, other prescription medications like Orlistat, Phentermine, and Liraglutide (Saxenda) are available to aid in weight loss. These medications work through various mechanisms, such as reducing appetite, increasing feelings of fullness, or blocking fat absorption. It is crucial to consult with a provider to find the best suitable medication based on medical history and weight loss needs.

3. Bariatric Surgery

For those with severe obesity or those who have not had success with other treatments, bariatric surgery may be an option. Procedures such as gastric bypass, sleeve gastrectomy, and adjustable gastric banding have been shown to produce significant and sustained weight loss. Bariatric surgery means committing to long-term lifestyle changes and regular medical check-ups.

4. Natural Supplements

For those looking for alternative approaches, natural supplements can offer additional support in their weight management journey. Some popular options include green tea extract, garcinia cambogia, and glucomannan.

These supplements can yield great results for weight loss by boosting metabolism, reducing appetite, or blocking fat absorption. However, it’s essential to consult a healthcare provider before starting any supplement regimen to ensure they are safe and appropriate for your health conditions and goals.

Conclusion

In conclusion, managing weight well means knowing and handling different choices and factors. Whether it’s changing your lifestyle, taking medicine, having weight-loss surgery, or using natural supplements, each method has unique benefits that fit individual health needs.

Understanding the costs of medications like Wegovy and looking into savings programs or insurance can make weight loss treatments easier to afford.

FAQ

Does Aetna cover weight loss injections?

Yes, Aetna does offer coverage for weight loss injections, but eligibility depends on the specific terms of your insurance policy. You will need to review your plan details or contact Aetna directly to find out if Wegovy or other weight loss medications are covered and what specific criteria or prior authorizations may apply.

Does Medicaid cover Wegovy?

As of now, Medicaid does not have a national policy for covering weight loss medications like Wegovy. However, some states may offer coverage under specific conditions. It is best to check with your state Medicaid office for more information on coverage and eligibility requirements.

Is Wegovy the only weight loss injection available?

No, Wegovy is not the only weight loss injection on the market. Other FDA-approved injectable medications for weight loss include Saxenda (liraglutide), Victoza (liraglutide), and Byetta (exenatide). These medications may have varying levels of insurance coverage and costs, so it’s best to check with your provider and insurance company before starting them.

Resources

FDA – Wegovy Medication Guide
Wegovy.com – Why Wegovy?
Ro.co – Cost of Wegovy With or Without Insurance

Does Aetna Cover Wegovy for Weight Loss? Complete Guide