Does Aetna Cover Zepbound for Weight Loss?
When considering weight loss medications like Zepbound, many people worry if their health insurance, especially from companies like Aetna, will pay for it.
Figuring out insurance coverage can be complex and overwhelming, especially when deciding if long-term treatment is affordable. Luckily, some insurers cover weight loss medications, including Zepbound. So does Aetna cover it for weight loss? The answer is, it depends.
In today’s article, we will discuss whether Aetna covers Zepbound for weight loss. We will explain the coverage criteria, factors that may affect coverage, and potential alternative options to help you make an informed decision about your weight management plan.
Understanding Zepbound as a Weight Loss Treatment
Zepbound is a brand-name subcutaneous injection newly approved by the FDA for chronic weight management.
It’s an injectable medication that combines the effects of two incretins: GLP-1 (Glucagon-like peptide-1) and GIP (Gastric inhibitory polypeptide).
These hormones help regulate blood sugar levels and appetite, making Zepbound a potential weight loss aid. However, it’s not intended for use in people with type 1 diabetes or diabetic ketoacidosis.
According to FDA approval, you can qualify for Zepbound if:
- Your body mass index (BMI) is 27 or higher and you have at least one weight-related condition like high blood pressure, type 2 diabetes, or high cholesterol.
- Your BMI is 30 or higher, regardless of other weight-related conditions.
How it works
Zepbound works by mimicking the actions of the incretins GLP-1 and GIP. These hormones are naturally released after eating and are involved in glucose metabolism and appetite regulation.
By enhancing the effects of these hormones, Zepbound promotes satiety, reduces food intake, and helps maintain blood sugar levels, contributing to weight loss.
As an injectable medication, users typically administer Zepbound on a weekly basis, following their provider’s instructions for optimal results.
READ More: How to Get a Zepbound Coupon for $25?
What’s the cost of Zepbound with and without insurance?
The price of Zepbound can vary a lot based on your insurance and the type of plan you have. If you don’t have insurance, Zepbound is quite expensive. Eli Lilly, the company that makes it, has set the price at $1,060 for a one-month supply. If your insurance doesn’t cover Zepbound, you might have to pay over $1,000 a month yourself. Depending on the strength and pharmacy, the cost can range from $500 to $1500 each month.
The good news is that some insurance plans do cover Zepbound. Here are a few situations you might encounter:
Covered with Savings: *If your insurance covers Zepbound and you get the Zepbound Savings Card from Eli Lilly, you can save a lot. With the savings card, you might only pay around $25 for a 1-month or 3-month supply.
Covered without Savings Card: If your insurance covers Zepbound but you don’t qualify for or use the savings card, you might still have to pay some money yourself. This cost could be between $10 to $300 each month, based on your insurance details like deductible, copay, and coverage specifics.
Does Aetna Cover Zepbound for Weight Loss?
According to Aetna’s coverage policy, they may cover medically necessary weight loss medications like Zepbound if you meet certain criteria.
Aetna finds the following weight loss programs, services, and devices necessary for medical reasons when certain conditions are met:
- Clinician Supervised Weight Loss Programs: Aetna covers up to 26 visits (either individual or group) each year with any approved provider for weight loss counseling for adults who are obese (BMI of 30 or higher). The number of visits for obese children will be decided by their doctor.
These criteria mean that if you’re seeking coverage for Zepbound, you may need to participate in a clinician-supervised weight reduction program. This program can involve individual or group counseling sessions that help guide and support you in your weight loss journey.
Make sure to check with Aetna and your healthcare provider to ensure you meet all the necessary requirements for coverage.
ALSO READ: Does Blue Cross Blue Shield Cover Zepbound?
Aetna’s Coverage Criteria for Weight Loss Medication
Many Aetna health and pharmacy plans do not cover weight loss medications. If your plan specifically excludes services related to treating obesity or weight control, then the rules listed below won’t apply to you and your claim for these medications will be denied.
Important Consideration:
If your plan does cover weight loss drugs, Aetna has outlined specific criteria you need to meet for these medications to be deemed medically necessary. Ensure you check your benefits plan for any exclusions or specific requirements.
For more details on the criteria for weight loss medications and guidelines, refer to Aetna’s policies on Antiobesity Agents.
How to check if Aetna covers Zepbound for weight loss?
If you’re an Aetna member and want to try Zepbound for weight loss, start by talking to your healthcare provider. Then follow these steps:
- Check Your Insurance Plan: Look at your Aetna insurance documents or online portal. Find sections about “weight loss medication,” “obesity treatments,” or “prescription drug coverage” to see if Zepbound is included.
- Contact Aetna Customer Service: Call Aetna’s customer service at 1-800-227-8862 or check the number on the back of your insurance card. Have your insurance ID number ready and inquire if Zepbound is covered and what it might cost you.
- Check the Drug List: Aetna has an online tool to see if Zepbound is on their drug list. If it’s listed, it’s usually covered, but check your specific plan for details on coverage and costs.
- Confirm Medical Needs: If Zepbound is covered, make sure you meet Aetna’s medical requirements, like certain BMI levels and weight-related health issues (e.g., high blood pressure, type 2 diabetes). These are often needed for coverage.
- Get Prior Authorization: Aetna may need prior authorization for weight loss drugs. This means your doctor must send documents showing you need Zepbound. Make sure all paperwork is correctly filled out to avoid delays.
By carefully following these steps, you can find out if Aetna will cover Zepbound for weight loss under your insurance plan. This way, you can make a smart decision about your weight management.
Factors That Affect the Coverage
Several factors can influence whether Aetna will cover Zepbound for weight loss. It’s essential to consider these elements to understand your coverage and optimize your chances of approval:
- Health Plan Type: The specific type of health insurance plan you have with Aetna may determine if weight loss medications are covered. Some plans may explicitly exclude obesity and weight control treatments.
- Medical Necessity: Aetna usually requires that medications like Zepbound are deemed medically necessary. This often means you must have a BMI over a certain threshold and possibly a related health condition, like type 2 diabetes or high cholesterol.
- Clinician-Supervised Programs: You might need to join a weight loss program overseen by a doctor. This usually involves regular meetings to help you manage your weight.
- Previous Attempts at Weight Loss: Evidence of previous weight loss attempts, including diet and exercise regimens or other medications, may be required to demonstrate your need for pharmaceutical intervention.
- Pre-authorization Requirements: Aetna might need approval before you get Zepbound. Your doctor has to show why you need the medication for it to be covered.
- Plan Specific Exclusions: Review your specific benefits plan for any exclusions related to weight reduction medications. Exclusions will override general coverage policies.
Alternative Options for Weight Loss Medication
If your insurance doesn’t cover Zepbound or it’s too expensive, don’t worry. There are many other weight loss medications and treatments which you can try. Each one works differently and has its own benefits and side effects. Talk to your doctor to find the best option for you.
- Orlistat (Alli/Xenical): Orlistat works by stoping the absorption of fats from the diet, thereby reducing calorie intake. It’s available in both prescription (Xenical) and over-the-counter (Alli) forms.
- Phentermine: This medication is an appetite suppressant that affects the central nervous system. It’s usually prescribed for short-term use due to the potential for dependence and side effects like increased heart rate and insomnia.
- Contrave (Naltrexone/Bupropion): Contrave combines two medications that target brain pathways related to hunger and cravings. It may be a good option if you struggle with emotional eating or food addiction.
- Liraglutide (Saxenda): Similar to Zepbound, Saxenda is a GLP-1 receptor agonist that helps control appetite and blood sugar levels. It’s administered via injection and is approved for long-term use. Side effects can include nausea, diarrhea, and hypoglycemia.
- Semaglutide (Wegovy): Another GLP-1 receptor agonist, Wegovy is specifically targeted for chronic weight management in adults. Studies have shown it can significantly aid in weight loss when combined with lifestyle changes.
Conclusion
In conclusion, to get Aetna’s coverage for weight loss medications like Zepbound, you need to understand your health plan, its rules, and any exclusions. It’s important to talk to your doctor and Aetna to check if you qualify and to know the steps for approval.
If Zepbound isn’t covered or affordable, numerous alternative medications are available, each offering distinct benefits and considerations. In the end, losing weight depends on using medicine, getting help from experts, and choosing to live a healthier life.
FAQ
What should I do if Zepbound isn’t covered by my insurance?
If Zepbound isn’t covered by your insurance, explore alternative weight loss medications with your doctor, check for discount programs or rebates, and consider paying out-of-pocket if feasible. Don’t forget to review your insurance plan annually for changes in coverage.
Does Aetna cover zepbound for weight loss Medicare?
No, Aetna mostly doesn’t cover Zepbound for weight loss under Medicare plans. Right now, Medicare Part D plans generally don’t include medications just for weight loss. This is true for most Aetna Medicare plans. So, it’s pretty unlikely that Zepbound would be covered for weight loss.
Can I use my HSA/FSA for Zepbound?
Yes, if the medication is deemed medically necessary by Aetna and prescribed by a doctor. But, check with your plan and healthcare provider first. Also, keep all receipts and paperwork for any HSA/FSA refunds for Zepbound.
