Does Aetna Cover Saxenda? Criteria, Copay, How to Appeal
Aetna covers Saxenda for weight loss only when your employer or plan has added weight-loss drugs. Where it is covered, you need a BMI of 30, or 27 with a weight-related condition.
- For weight loss
- Employer option
- For type 2 diabetes
- Covered on formulary
- Prior authorization
- Required
- Weight rule
- A BMI of 30, or 27 with a weight-related condition
A quick look at Saxenda
About 13 hours is the half-life: by 13 h, half is gone, while about 3% remains after five half-lives (2.7 d).
The SCALE findings for Obesity and Prediabetes, 56 weeks showed 7.4% of body weight, versus 3% on placebo.
Sources: FDA label (DailyMed).
Does Aetna cover Saxenda?
| Medicine | Approved for | Status | Prior authorization |
|---|---|---|---|
| Saxenda | Weight loss | Employer option | Required |
Sources: Novo Nordisk pricing, NovoCare, aetna.com.
The published policy
Aetna is a commercial insurer (CVS Health)
- The plan sponsor makes the choice
Read the full policy document at aetna.com.
Source: aetna.com.
Prior authorization checklist
- Diagnosis: your chart shows the weight diagnosis requested by the plan.
- Baseline requirement: BMI of 30 or higher
- BMI 27 or higher applies when you have a weight-related condition
- A lifestyle program comes first: 6 months in a weight program
- To renew and keep coverage: 5% of baseline weight lost
- Records: your height and weight as measured, your weight-related conditions, and the diet and activity program you tried.
- Filing: your prescriber submits the prior authorization, not you.
Source: aetna.com.
The appeal if you are denied
| Denial reason | What to send or ask |
|---|---|
| The plan excludes weight-loss drugs | This is a plan design choice. Ask the benefits team at your employer: will weight-loss drugs be added at renewal? |
| Criteria not met | Have your prescriber send a new request with your measured BMI and every weight-related condition listed in your chart. BMI of 30 qualifies, while 27 qualifies if you have a weight-related condition. |
| No lifestyle program on file | First send records of a weight program for 6 months. |
| Renewal denied | Send your starting and current weight. To renew, you must lose 5% of baseline weight. |
| The drug is not on the plan's list | Request a formulary exception, and ask which GLP-1 the plan prefers instead. |
- Get the denial letter, which states the exact rule that you did not meet.
- The appeal your prescriber files includes chart notes in response to the rule.
- If the plan's own appeal fails, ask for an external review by an independent reviewer.
Source: aetna.com.
State and plan differences
| Plan | For weight loss | Prior authorization |
|---|---|---|
| Medicare | Bridge program only | Required |
| Medicaid | Varies by state | Required |
 Cigna (Evernorth / Express Scripts) | Plan dependent | Required |
 UnitedHealthcare (Optum Rx) | Plan dependent | Required |
 Blue Cross Blue Shield | Plan dependent | Required |
 Kaiser Permanente | Plan dependent | Required |
 CVS Caremark | Plan sponsor choice | Required |
| Express Scripts | Plan sponsor choice | Required |
| Optum Rx | Plan sponsor choice | Required |
 Humana | Bridge program only | Required |
| TRICARE | Prime and Select only | Required |
| VA (Veterans Health Administration) | Covered with criteria | Required |
 GEHA | Covered with PA | Required |
 Ambetter (Centene) | Excluded | Required |
| ACA Marketplace plans | Rare | Required |
 Navitus | Plan sponsor choice | Not listed |
 Amerigroup (Elevance Medicaid) | Follows state Medicaid | Required |
Today, weight-loss GLP-1s are covered in 10 states. See every state