The facts
Weight loss
Plan-dependent
Type 2 diabetes
Not indicated
Prior auth
Required
Typical cost
Card to $25/mo, if covered
The criteria, as published
5 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
“WEGOVY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 0.25 MG/0.5ML, 0.5 MG/0.5ML, 1 MG/0.5ML, 1.7 MG/0.75ML, 2.4 MG/0.75ML (semaglutide-weight management) PB”
fm.formularynavigator.com · 2026-10-01- BMI threshold
BMI 35+ for adults 18 and over
“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
- Not published in what we readAsk which conditions the Wegovy criteria accept alongside BMI.
- Lifestyle program
At least 6 months in a weight management program with diet, activity and behavior changes
“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
- Not published in what we readAsk whether another drug has to be tried before Wegovy.
- 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?
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
Zepbound added to the Standard Control formulary effective Oct 1, 2026
“Formulary Updates for Standard Control Formulary™ effective October 1, 2026 … Products to be added to the formulary: Formulary Additions Drug Class Product(s) Added Endocrine and Metabolic, Antiobesity ZEPBOUND”
aetna.com · 2026-07-01
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 Wegovy, so your prescriber answers the plan's questions rather than guessing at them.
- 3
Your prescriber documents the clinical picture
BMI: BMI 35+ for adults 18 and over. Any weight-related conditions, with diagnosis codes. Lifestyle program: At least 6 months in a weight management program with diet, activity and behavior changes.
- 4
Answer step therapy, if there is any
Ask whether another drug must come first. If you have already tried one, the request should list it with dates and the reason it stopped.
- 5
Submit, then track it
Your prescriber sends the plan’s form with the notes. Our Wegovy prior authorization letter template covers the cover letter. 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
Log in at caremark.com and run "Check Drug Cost & Coverage" for Wegovy. If it shows not covered, ask member services (number on your Aetna ID card) whether your employer's plan includes the weight-loss medication benefit and what the prior-auth criteria are.
Coverage is plan-specific: this page reports what Aetna publishes, not a promise about your plan. Not medical or insurance advice.
