The facts
Weight loss
Generally no
Type 2 diabetes
Yes, with PA
Prior auth
Typical
Typical cost
Card to $25/mo (T2D only)
The criteria, as published
3 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 Aetna's 2026 drug guide (diabetes listing)
“OZEMPIC (0.25 OR 0.5 MG/DOSE) SUBCUTANEOUS PB SOLUTION PEN-INJECTOR 2 MG/3ML (semaglutide)”
fm.formularynavigator.com · 2026-09-01- BMI threshold
- Not published in what we readAsk member services for the written prior authorization criteria for Ozempic.
- Qualifying conditions
Type 2 diabetes
“Authorization may be granted for a diagnosis of type 2 diabetes mellitus … The patient has experienced an inadequate treatment response, intolerance, or has a contraindication to metformin”
aetna.com · 2024-10-27- Lifestyle program
- Not published in what we readAsk whether a diet, exercise or behavioral program has to be documented, and for how long.
- 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 … The patient has experienced an inadequate treatment response, intolerance, or has a contraindication to metformin”
aetna.com · 2024-10-27- Quantity limit
- Not published in what we readAsk what quantity limit applies to each fill.
- Renewal
- Not published in what we readAsk how long an approval lasts and what the renewal needs.
- Plan can exclude it?
- Not published in what we readAsk HR or member services whether your plan includes the weight-loss drug benefit.
- 2026 change
- Not published in what we readAsk whether Ozempic'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 member services whether your plan covers Ozempic for weight management at all. A plan that excludes the category will refuse a perfect request.
- 2
Get the criteria in writing
Ask for the written prior authorization criteria for Ozempic, so your prescriber answers the plan's questions rather than guessing at them.
- 3
Your prescriber documents the clinical picture
Current and baseline BMI, with dates. Conditions: Type 2 diabetes. Records of any diet, exercise or behavioral program.
- 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
Have your prescriber submit the Aetna/Caremark prior auth with your type 2 diabetes diagnosis and metformin history documented, then confirm your tier price with caremark.com's "Check Drug Cost & Coverage" tool.
Coverage is plan-specific: this page reports what Aetna publishes, not a promise about your plan. Not medical or insurance advice.
