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Coverage requirements for weight loss When Wegovy is prescribed solely for weight loss, Aetna requires the following: A baseline BMI of 35 or higher in adults, or a BMI in the 95th percentile for age and sex in children aged 12 to 17 Participation in a weight management program (behavior modification, reduced-calorie diet, and increased physical activity) for at least six months before prescribing Wegovy Coverage requirements for cardiovascular risk reduction When Wegovy is prescribed to reduce the risk of major adverse cardiovascular events (MACE) in adults, Aetna requires the following: A baseline BMI of 27 or higher No diagnosis of type 2 diabetes A reduced-calorie diet and increased physical activity Simultaneous treatment with other cardiovascular medications (such as beta blockers) if medically possible A history of cardiovascular disease and at least one of the following: A previous stroke or heart attack Symptomatic peripheral arterial disease A previous heart surgery (heart bypass surgery, stents placed in heart arteries, or balloon procedures to open blocked blood vessels) Coverage requirements for liver disease When Wegovy is prescribed to treat a liver disease called noncirrhotic metabolic dysfunction-associated steatohepatitis, Aetna requires the following: A gastroenterologist or hepatologist has written the prescription or been consulted by the prescriber A reduced-calorie diet and increased physical activity A baseline diagnosis of stage F2 to F3 fibrosis, confirmed by either a noninvasive liver disease assessment (such as ultrasound-based elastography) or a pathology report from a liver biopsy Ongoing coverage requirements Note that Aetna only authorizes Wegovy HD 7.2 mg injections for weight loss in adults
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Start by researching the latest clinical data, focusing on how tirzepatide has been shown to impact weight loss
This follow-up is essential for timely identification of pregnancy, including potential ectopic pregnancy
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