Aetna GLP-1 Prior Authorization Guide: Verbatim PA Criteria for Wegovy, Zepbound, Saxenda, Ozempic, and Mounjaro (2026)

Aetna covers about 39 million members and publishes its GLP-1 prior-authorization criteria across separate pharmacy clinical policy bulletins — one per drug. We pulled all 9 primary Aetna and CMS policy URLs directly on 2026-05-09 (HTTP/2 200 verified) and quote them verbatim below. If your Aetna PA submission has been delayed or denied, this is the source-of-truth for every clause your prescriber can address.

The 9 policy documents you need to know

Aetna does not publish a single “GLP-1 master policy.” Each drug has its own pharmacy clinical policy bulletin (PA), plus a medical CPB for the underlying weight-reduction framework, plus the new CMS Medicare GLP-1 Bridge that overlays Aetna's MA-PD plans starting 07/01/2026.

Wegovy: PA criteria verbatim from bulletin 4774-C

Wegovy is Aetna's preferred commercial GLP-1 since CVS Caremark's July 2025 formulary swap (more on that below). Adult initial criteria from 4774-C UDR 08-2023 v2 (effective 05/01/2024):

• Patient must be 18 years of age or older.
• Comprehensive weight-management program participation for at least 6 months prior to drug therapy.
• BMI ≥ 30 kg/m², OR BMI ≥ 27 kg/m² with “at least one weight related comorbid condition.”

Pediatric (12-17): BMI “in the 95th percentile or greater standardized for age and sex” + same 6-month program.

Cardiovascular pathway for non-diabetic patients: established cardiovascular disease, on guideline-directed management and therapy (GDMT), patient does NOT have type 2 diabetes. This is the SELECT-trial pathway — see our SELECT trial cardiovascular benefits article for the underlying evidence.

Continuation (verbatim): “lost at least 5 percent of baseline body weight OR…continued to maintain their initial 5 percent weight loss.” Initial approval is 7 months (not 3, not 8 — this is a frequently-confused detail); continuation/reauthorization is 12 months.

Quantity limits: 0.25–1 mg pens = 2 mL per 21 days (6 mL per 63 days at home delivery); 1.7–2.4 mg pens = 3 mL per 21 days (9 mL per 63 days).

Zepbound: 6947-C plus the 6981-A exception caveat

Zepbound has a structural complication you will not find in Cigna's policies. Two bulletins apply depending on your plan's formulary code:

• 6947-C P04-2025 (effective 07/01/2025) — the standard PA. Adult criteria (verbatim): “BMI greater than or equal to 30 kg/m2” OR “BMI greater than or equal to 27 kg/m2” with at least ONE weight-related comorbid condition (verbatim list: “hypertension, type 2 diabetes mellitus, dyslipidemia”), AND a 6-month comprehensive weight-management program prior to drug therapy.
• 6981-A P04-2025 — Zepbound Exception — applies on plan-formulary codes ACCF / ACF / ACFC / SCCF / SF / SFC / VF / VFC. On these formularies Wegovy is the preferred step and Zepbound requires the exception process. Most CVS Caremark commercial formularies adopted this exception framework when Caremark designated Wegovy preferred in July 2025.

OSA pathway in 6947-C: moderate-to-severe obstructive sleep apnea in adults with obesity, with “apnea-hypopnea index (AHI) of at least 15 events per hour.” Aetna Medicare Part D may cover Zepbound under this OSA indication (the weight-loss-only indication is statutorily excluded). See our SURMOUNT-OSA tirzepatide / sleep apnea evidence article for the underlying RCT data.

Continuation: “lost at least 5 percent of baseline body weight OR…continued to maintain their initial 5 percent weight loss.”

Quantity limits (all strengths): 2 mL (1 package of 4 pens) per 21 days at retail; 6 mL (3 packages of 4 pens, total 12 pens) per 63 days at home delivery.

Medicare GLP-1 Bridge (07/01/2026): only the Zepbound KwikPen formulation is available to Aetna MA-PD members through the bridge — single-dose vials and single-dose pens are excluded. See the Bridge section below.

Saxenda: the 4% continuation rule (NOT 5%)

Aetna still publishes a distinct PA bulletin for Saxenda (liraglutide for chronic weight management) with criteria that do NOT match the semaglutide and tirzepatide bulletins. This is the most-overlooked detail in third-party PA explainers. From bulletin 1227-C P08-2024_R (12/19/2024):

• Adult eligibility: BMI “30 kg/m2 or greater (obese), or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition” — verbatim list: “hypertension, type 2 diabetes mellitus, or dyslipidemia.” (Notice this list is shorter than Wegovy's — only 3 conditions, not 11.)
• Pediatric (12-17): BMI “corresponding to 30 kg/m2 or greater for adults by international cut-offs (Cole Criteria)” + 6-month program.
• 6-month program (verbatim): “ 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.”
• Adult continuation (verbatim): “lost at least 4 percent of baseline body weight OR…maintain their initial 4 percent weight loss.” Not 5%. This is the frequently-confused detail.
• Pediatric continuation: “at least 1 percent reduction in BMI from baseline.”
• Medicare GLP-1 Bridge: Saxenda is NOT included in the bridge. MA-PD members who want a covered weight-loss GLP-1 path under the bridge have to switch to Wegovy, Zepbound KwikPen, or Foundayo.
• Quantity limits: 15 mL (1 package of five 3 mL pens) per 25 days; 45 mL (3 packages, total 15 pens) per 75 days.

Mounjaro: type-2-diabetes coverage with metformin-first step

From bulletin 5468-C UDR 05-2024 (last reviewed 10/27/2024). Initial PA verbatim:

“The patient has NOT been receiving a stable maintenance dose of the requested drug for at least 3 months and ONE of the following criteria are met” — either metformin inadequacy, intolerance, or contraindication, OR “combination therapy AND has an A1C of 7.5 percent or greater.”

Bypass routes around metformin: eGFR < 30 mL/min/1.73m² or established cardiovascular disease (these are spelled out in the parallel Ozempic bulletin and apply to Mounjaro by analogous policy logic — clarify with PA staff if unsure).

Continuation: stable maintenance ≥ 3 months AND “demonstrated a reduction in A1C since starting this therapy.” The bulletin does not specify a minimum A1C drop magnitude — just any reduction. Approval period: 36 months.

Quantity limits (verbatim): “4 single- dose pens or single-dose vials (2 mL) per 21 days OR 12 single-dose pens or single-dose vials (6 mL) per 63 days.”

Aetna Medicare Part D plans cover Mounjaro for type 2 diabetes (NOT for off-label weight loss). See Aetna's consumer Medicare-coverage page for the standard caveat.

Ozempic: same metformin-first step + four bypass routes

From bulletin 2439-C UDR 05-2024 (last reviewed 10/27/2024). Initial PA — patient must NOT be on stable GLP-1 maintenance ≥ 3 months AND meet ONE of:

• “inadequate treatment response, intolerance, or has a contraindication to metformin”
• “requires combination therapy AND has an A1C of 7.5 percent or greater”
• “estimated glomerular filtration rate [eGFR] less than 30 mL/min/1.73m2”
• “established cardiovascular disease”

Continuation: stable maintenance ≥ 3 months AND demonstrated A1C reduction since starting GLP-1 therapy (or CKD/CVD indication).

MACE/CV indication (verbatim): “reduce the risk of major adverse cardiovascular events…in adults with type 2 diabetes mellitus and established cardiovascular disease.” This is the SUSTAIN-6-trial pathway.

Quantity limits: 2 mg/1.5 mL = 1 pen per 21 days; 2 mg/3 mL = 1 pen per 21 days; 4 mg/3 mL = 1 pen per 21 days; 8 mg/3 mL = 1 pen per 21 days.

Foundayo (orforglipron): no Aetna primary source as of 2026-05-09

Foundayo received FDA approval on 04/01/2026. Aetna's bulletin update cadence has not yet incorporated it as of our verification date. We do NOT cite specific Foundayo Aetna criteria because no primary source exists yet. Coverage is currently determined at the plan / employer level.

Where covered, expect criteria to mirror the Wegovy 4774-C framework (BMI ≥ 30 or ≥ 27 with comorbidity, 6-month comprehensive weight-management program, 5% baseline weight loss for continuation). Re-verify Aetna's primary source quarterly.

For Aetna MA-PD members: all Foundayo formulations ARE included in the CMS Medicare GLP-1 Bridge at $50/month flat copay beginning 07/01/2026 — see next section.

The CVS Caremark July 2025 formulary swap (the dominant 2026 denial driver)

Aetna's pharmacy benefit manager is CVS Caremark — both are CVS Health subsidiaries since 2018. In July 2025, CVS Caremark removed Zepbound from MOST commercial formularies in favor of Wegovy as the single preferred GLP-1 for weight loss. This Caremark formulary decision overrides bulletin 6947-C at point-of-sale on the affected formulary codes. The exception bulletin 6981-A P04-2025 documents the formulary codes where Wegovy is the preferred step (ACCF, ACF, ACFC, SCCF, SF, SFC, VF, VFC).

Practical implication: a patient who was approved for Zepbound through 2024 may now receive a denial in 2026 even if they meet 6947-C criteria, because their plan's formulary now requires a Wegovy trial first. The fastest resolution is to switch to Wegovy (which Aetna will approve under 4774-C) rather than fight the formulary on Zepbound. If the patient cannot tolerate semaglutide, the prescriber can invoke the 6981-A exception process.

Medicare GLP-1 Bridge: 07/01/2026 through 12/31/2027

Effective July 1, 2026, Aetna MA-PD members gain a time-limited GLP-1 weight-loss coverage path through the CMS-mandated Medicare GLP-1 Bridge. Key terms:

• Drugs included: Wegovy (all formulations), Zepbound KwikPen only (NOT vials or single-dose pens), Foundayo (all formulations).
• Drugs excluded: Saxenda is NOT in the bridge.
• Eligibility: BMI ≥ 27 plus heart disease or prediabetes.
• Cost: $50/month flat copay.
• Important caveats: the $50 copay does NOT count toward the deductible OR toward the $2,100 out-of-pocket cap. The bridge runs through December 31, 2027; coverage after that reverts to whatever Part D rules exist at that time.

See our Medicare Part D coverage guide for the broader MA-PD context.

Aetna Better Health (Medicaid managed care): state PDLs supersede

Aetna Better Health is Aetna's Medicaid managed-care arm and operates under state-specific Preferred Drug Lists (PDLs) that supersede everything above for Medicaid members. For example, Aetna Better Health of Michigan publishes its 2026 Anti-Obesity Agents PDL as a separate PDF on aetna.com. Medicaid GLP-1 weight-loss coverage varies dramatically by state per CMS optional-coverage rules — consult your state Medicaid PDL directly before filing any Medicaid claim.

What does this actually mean for your PA submission?

The most common reasons Aetna PA submissions for GLP-1 weight-loss drugs are delayed or denied:

• Filing the wrong continuation milestone for Saxenda. Saxenda continuation requires 4% baseline weight loss, not 5%. Submitting reauth at 5% will pass; submitting based on a misread “Saxenda needs 5%” will confuse staff.
• Submitting Wegovy reauth at month 3. The first weight check is at month 7, not month 3. There is no interim 3-month milestone in 4774-C.
• Submitting Zepbound on a formulary code where Wegovy is preferred. If your formulary code is in the ACCF / ACF / ACFC / SCCF / SF / SFC / VF / VFC list, the 6981-A exception applies — try Wegovy first.
• Missing the 6-month comprehensive program documentation. Aetna's 6-month requirement is stricter than some other insurers' 3-month requirements. The chart needs to show behavioral modification, reduced-calorie diet, AND increased physical activity for at least 6 months.
• Trying Mounjaro / Ozempic for weight loss without type 2 diabetes. Both bulletins gate on metformin first AND require T2D coverage. Use Wegovy or Zepbound under the weight-loss bulletins instead, or pursue compounded options through compounded semaglutide telehealth providers if cash-pay is required.
• Attempting weight-loss coverage on Aetna MA-PD before 07/01/2026. Federal Part D excludes weight- loss drugs until the bridge starts. Wegovy MACE indication and Zepbound OSA indication are the only non-bridge MA-PD coverage paths today.

If Aetna denies your GLP-1: appeals + alternatives

If your PA is denied, Aetna's formal appeal process gives you 180 days to submit a written appeal (commercial plans). Steps:

1. Request the written denial letter that names the specific bulletin clause your submission failed to satisfy.
2. Have your prescriber draft a Letter of Medical Necessity using our GLP-1 PA letter generator, which embeds the specific 4774-C / 6947-C / 5468-C / 2439-C / 1227-C criteria into the letter template.
3. File the internal appeal within 180 days; include the LOMN, baseline BMI, comorbidity documentation, the 6-month comprehensive weight-management program documentation, and (if reauth) the documented 5% (or 4% for Saxenda) baseline weight-loss calculation.
4. If the internal appeal is denied, request an external review through Aetna's independent review organization. External review decisions are binding on commercial plans.

While the appeal is in flight, many patients use cash-pay compounded semaglutide or tirzepatide as a bridge. For our verified telehealth provider directory, see best semaglutide providers and best tirzepatide providers.

Verification log

Every Aetna and CMS policy URL cited in this article was verified HTTP/2 200 by direct WebFetch on 2026-05-09. The version stamps in each document header as of that date are recorded in the policy table near the top of this article.

The following items are not in this article because they could not be verified to a specific policy clause in this pass:

• A standalone Aetna PA bulletin for Foundayo — none exists on aetna.com as of 2026-05-09 (FDA approval was 04/01/2026).
• Specific eGFR / CVD bypass-route language inside the Mounjaro 5468-C bulletin (the exhaustive bypass list is spelled out in the parallel Ozempic 2439-C bulletin and applies to Mounjaro by analogous policy logic — confirm with PA staff if needed).
• State-by-state Aetna Better Health PDL details — these are separate documents per state and change annually.
• The full text of any Aetna employer-group customizations that override the bulletins above — these are plan-specific and not centrally published.