The facts
Weight loss
Plan-dependent
Type 2 diabetes
Yes, with PA
Prior auth
Required
Typical cost
Plan-specific
The criteria, as published
7 of 9 criteria are stated in the Aetna documents we read. Tap a row for the exact wording. Where a cell says not published, the documents we read do not say, and the line under it is how to find out.
- Formulary status
Preferred brand (PB) on the 2026 Standard Control Plan drug guide
“MOUNJARO SUBCUTANEOUS SOLUTION AUTO- INJECTOR 10 MG/0.5ML, 12.5 MG/0.5ML, 15 MG/0.5ML, 2.5 MG/0.5ML, 5 MG/0.5ML, 7.5 MG/0.5ML (tirzepatide) PB”
fm.formularynavigator.com · 2026-10-01- BMI threshold
BMI 35+ under Aetna's weight-loss policy, which lists Mounjaro
“The patient is 18 years of age or older. The patient has participated in a comprehensive weight management program that encourages behavioral modification, reduced-calorie diet, AND increased physical activity with continuing follow-up for at least 6 months prior to using drug therapy. The patient has a baseline body mass index (BMI) greater than or equal to 35 kg/m 2 .”
aetna.com · 2026-04-10- Qualifying conditions
Type 2 diabetes (diabetes policy)
“Authorization may be granted for a diagnosis of type 2 diabetes mellitus when the following criteria is met … The patient has experienced an inadequate treatment response, intolerance, or has a contraindication to metformin … The patient requires combination therapy AND has an A1C of 7.5 percent or greater”
aetna.com · 2024-10-27- Lifestyle program
At least 6 months in a weight management program with diet, activity and behavior changes (weight-loss policy)
“The patient is 18 years of age or older. The patient has participated in a comprehensive weight management program that encourages behavioral modification, reduced-calorie diet, AND increased physical activity with continuing follow-up for at least 6 months prior to using drug therapy. The patient has a baseline body mass index (BMI) greater than or equal to 35 kg/m 2 .”
aetna.com · 2026-04-10- Step therapy
Metformin first, unless it failed, was not tolerated or is contraindicated
“Authorization may be granted for a diagnosis of type 2 diabetes mellitus when the following criteria is met … The patient has experienced an inadequate treatment response, intolerance, or has a contraindication to metformin … The patient requires combination therapy AND has an A1C of 7.5 percent or greater”
aetna.com · 2024-10-27- Quantity limit
4 single-dose pens or vials per 21 days
“QUANTITY LIMITS APPLY 4 single-dose pens or single-dose vials (2 mL) per 21 days”
aetna.com · 2024-10-27- Renewal
- Not published in what we readAsk how long an approval lasts and what the renewal needs.
- Plan can exclude it?
Yes: Aetna lets employers include or exclude GLP-1 coverage for weight management
“You can choose to customize your benefits to include or exclude GLP-1 drug coverage for weight management.”
aetna.com · 2026-10-04- 2026 change
- Not published in what we readAsk whether Mounjaro's status changed this year or changes at your next renewal.
Who actually decides this
Not the logo on your card, most of the time. Three parties sit between you and the answer, and knowing which one is saying no tells you who to ask.
- 1
The pharmacy benefit manager
No single PBM to name here, which is itself the finding. Different plans under this name use different benefit managers, so one national statement about the formulary would be wrong.
- 2
Your employer, if the plan comes through work
Weight-loss drugs are usually a category an employer buys or declines, not something the insurer includes by default. That is why two people holding identical cards get opposite answers, and why the useful question for member services is whether your plan includes the weight-loss medication benefit at all, before anything about criteria.
How prior authorization works here
Six steps. Specifics come from the criteria above; where Aetna does not publish one, the step says what to ask for.
- 1
Confirm the benefit exists
Before any paperwork, ask whether your plan includes the weight-loss drug benefit. On whether a plan can leave it out, the documents say: Yes: Aetna lets employers include or exclude GLP-1 coverage for weight management.
- 2
Get the criteria in writing
Ask for the written prior authorization criteria for Mounjaro, so your prescriber answers the plan's questions rather than guessing at them.
- 3
Your prescriber documents the clinical picture
BMI: BMI 35+ under Aetna's weight-loss policy, which lists Mounjaro. Conditions: Type 2 diabetes (diabetes policy). Lifestyle program: At least 6 months in a weight management program with diet, activity and behavior changes (weight-loss policy).
- 4
Answer step therapy, if there is any
What the documents say: Metformin first, unless it failed, was not tolerated or is contraindicated. If you already tried that drug, or cannot take it, the request should say so with dates.
- 5
Submit, then track it
Your prescriber sends the plan’s form with the notes. Write down the date and the reference number, and ask how you will hear back.
- 6
Plan for the renewal
Ask how long the approval lasts and what the renewal needs, so the gap does not catch you out.
Get your real answer
For diabetes, have your prescriber submit Aetna's Mounjaro prior authorisation with the diagnosis and your metformin history, then confirm the tier price with the Check Drug Cost and Coverage tool at caremark.com. If weight is the goal, first ask member services (number on your Aetna ID card) whether your plan includes the weight-management drug benefit; if it does, Aetna's weight-loss policy applies to tirzepatide under either brand name, and Zepbound has been a preferred brand on the Standard Control formulary since 1 October 2026, so read the Zepbound answer too and check your plan.
Coverage is plan-specific: this page reports what Aetna publishes, not a promise about your plan. Not medical or insurance advice.
