Does Aetna Cover Ozempic for Weight Loss? Everything You Need to Know

Weight loss drugs have become a critical component of people’s health journeys, particularly those with obesity and its related chronic diseases. Among them, Ozempic (semaglutide) has captured a lot of attention—the original purpose of Ozempic was to treat type 2 diabetes, but has also been noted to aid with weight loss. If you’re someone whose insurance plan is administered by Aetna, you may have wondered, does Aetna cover Ozempic for weight loss?
This article will detail what you need to know about Ozempic, how it compares to drugs such as Wegovy, and how Aetna addresses coverage for this up and coming drug. It will also provide tips on how you can get your provider and insurance company to approve the use of Ozempic (for weight loss) as your primary intention.

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What is Ozempic?

These medications have an effect similar to the natural hormone GLP-1. They:

Increase insulin secretion
Decrease glucagon secretion (decreasing blood sugar)
Decrease emptying of the stomach
Decrease appetite

Although Ozempic was not designed for weight loss, the medication’s effects on appetite and metabolism have recently led many patients to experience clinically significant weight loss as a side effect.
The Rise of Ozempic for Losing Weight Ozempic has become a popular off-label choice for people with obesity—even those without diabetes—due to its weight-loss effects. As a result, there has been a significant rise in demand for the medication, a shortage of supplies, and increased scrutiny from healthcare providers and insurance companies. In response to the popularity of using semaglutide for weight loss, Novo Nordisk, the maker of Ozempic, released Wegovy, a stronger dose of semaglutide approved for chronic weight management, in 2021.

Insurance Coverage of Prescription Medications

Health insurance companies (e.g. Aetna) will typically either have or use formularies (a list of covered medications) that specify which medications will be covered by insurance. Even formularies use coverage tiers:

Tier 1 – Generic medications (low co-pay, low cost)
Tier 2: Preferred brand-name drugs (moderate co-pay),
Tier 3: Non-prefetch brand-name drugs (higher co-pay),
Tier 4/5 – Specialty drugs (highest out-of-pocket expense / cash co-pay, usually requires prior authorization / approval)

if your intended use falls under these indications.

Knowing Aetna’s policy related to Ozempic

Typically, insurance companies will follow FDA guidelines when determining coverage.

Aetna is currently covering Ozempic, but only for individuals diagnosed with type 2 diabetes and/or cardiovascular disease that also meet specific criteria.
If your doctor prescribed Ozempic exclusively for weight loss and you do not have an underlying diagnosis of diabetes,

it will generally not be covered for one major reason: there is an FDA-approved alternative for weight management (Wegovy), and insurance companies will routinely deny reimbursement for medications that have been prescribed off-label as long as there exists at least one FDA-approved alternative available. This being said, there are many common exceptions.

Will Aetna Cover Ozempic for Weight Loss?

Short Answer: Typically not.
But here is a larger discussion:

Aetna’s policies contians that they will cover Ozempic for its FDA approved uses, such as controlling blood sugars in a patient with type 2 diabetes. Ozempic for weight loss only is considered off label and generally will not be covered.

However, some polarizations have been covered under these conditions:

A doctor’s justification for using Ozempic for someone with medical necessity
A prior authorization request, which is completed and approved
Patient has comorbidities, such as metabolic syndrome, prediabetes, or polycystic ovarian syndrome [PCOS]

IMPORTANT:
Even if a prior authorization was a success, off label use is not guaranteed, and coverage will be based on the following considerations:

Your specific plan (employer sponsored, individual marketplace, Medicaid/Medicare)
Your state’s insurance regulations
Aetna’s pharmacy benefit manager (PBM) policies

What is Off-Label Use, and Why Does It Matter?

While legally permissible and commonplace in medical practice, insurers (like Aetna) often will not reimburse for off-label uses unless:

All other treatment options have been exhausted
Ozempic, for weight loss, is considered off-label in this regard, unless used in conjunction with a treatment plan that includes the treatment of diabetes or another covered condition.

How to Check if You are Covered?

Log onto your Aetna member portal
Search for “Ozempic” or semaglutide in your plan drug formulary
Check your Summary of Benefits
Identify the tier of Ozempic and if prior authorization is needed
Call Aetna customer service
Ask the customer service rep the direct question, “Is Ozempic covered by my plan for weight loss?” Be very specific.
Ask your doctor to initiate a prior authorization
If it is medically appropriate, this may hel

Steps to Appeal a Denied Claim

If Aetna denies coverage of the Ozempic, you can appeal this determination. Here are the steps to do it:

Step 1: Get a Written Denial

Ask for a letter stating their claim was denied and the reasons why.

Step 2: Gather Evidence

Things to include:

Medical records
Doctor’s letter
Evidence of the failures of other interventions

Step 3: Appeal

Follow the directions on the denial letter; most allow you to appeal by mail or online.

Step 4: External Review (if necessary)

If your internal appeal is unsuccessful, you can request an external review by an independent third-party reviewer.

Options Other than Ozempic for Weight Loss

if they don’t cover Ozempic, here are some options that may be more “insurance-friendly”:

Wegovy (semaglutide) – FDA approved for obesity and is more likely be covered
Saxenda (liraglutide) – similar mechanism and a daily injection
Contrave (bupropion/naltrexone) – oral pill that is used to help with the chronic weight management
Qsymia (phentermine/topiramate) – oral prescription weight loss medication.
Generic phentermine – appetite suppressant that is much cheaper, but only used in short-term interventions.

Ways to Manage Out-of-Pocket Costs

Although Ozempic may not be covered by insurance, you can usually make it less expensive by:

Using a manufacturer coupon through Novo Nordisk
Applying for patient assistance programs
Comparing pharmacy prices using any online price comparison tool
Asking your doctor for samples

In Conclusion:

Your Options Related to Aetna
So, does Aetna cover Ozempic prescribed for the purpose of weight loss? Normally not, unless prescribed for Type 2 diabetes (or possibly some extenuating medical hardship). However, through appropriate channels (before medication is started) or prior authorization, keeping documentation for medical necessity of this medication and appealing a denial of coverage, you may be able to obtain approval for coverage.

If Ozempic is not approved, don’t give up yet. Wegovy and Saxenda, as well as other FDA-approved medication for weight loss, may provide a greater chance for obtaining coverage, and they may be more direct in helping improve your ability to lose weight.