Aetna (CVS Health)

Insurer (Caremark-administered) · updated August 8, 2026

Coverage right now

Foundayo™ (orforglipron) Covered
Wegovy® (semaglutide injection) Preferred
Wegovy® tablets (oral semaglutide) Preferred
Zepbound® (tirzepatide) Exception only

Criteria are essentially identical to the Caremark template (same BMI wording, 6-month program requirement, 5% reauth gate, same quantity limits). The difference is formulary architecture: standard Aetna commercial formularies made Zepbound exception-only after July 2025 with a step through Wegovy, while FE-compatible plans kept it PA-covered. Many Aetna plans exclude weight-loss drugs entirely (CPB 0039).

Drug status

Drug	Status	Detail	Confidence
Wegovy® (semaglutide injection)	Preferred from Jul 1, 2025	Preferred GLP-1 with PA on standard commercial formularies since 7/1/2025. source	high
Zepbound® (tirzepatide)	Exception only from Jul 1, 2025 to Sep 30, 2026	Non-formulary on standard commercial formularies (ACCF/ACF/ACFC/SCCF/SF/SFC/VF/VFC) — exception requires inadequate response/intolerance/contraindication to Wegovy. Covered with PA on FE-compatible plans. Returns as additional preferred template option 10/1/2026. source	high
Zepbound® (tirzepatide)	Preferred from Oct 1, 2026	Returns as additional preferred option on Caremark-administered templates. source	high
Wegovy® tablets (oral semaglutide)	Preferred from Jan 5, 2026	Same preferred status as injectable on Caremark template formularies; Aetna-specific policy document not located. source	medium
Foundayo™ (orforglipron)	Covered from Jun 1, 2026	New-to-market block removed on Caremark template 6/1/2026 where plans cover weight loss; Aetna tier placement not yet published. source	medium

What preferred, covered and exception only mean

Preferred: On the formulary at the plan's best tier for this class. Usually still needs prior authorization — preferred is not the same as automatic.
Covered: On the formulary, but not the plan's first choice for this class. Often a higher copay tier than a preferred drug.
Non preferred: On the formulary at a disadvantaged tier, or reachable only after trying a preferred drug first.
Exception only: Not routinely covered. Obtainable only through a formulary-exception request that meets the plan's published criteria.
Excluded: Not on the formulary at all. A benefit exclusion is a different fight from a PA denial and is appealed differently.
Varies: The payer's own documents differ by plan or line of business, so a single answer here would be wrong.
Unknown: Not yet verified against a primary document. Recorded as absent rather than guessed.
N/A: Not applicable to this payer.

Prior authorization criteria

high

PA required: Yes where the plan includes a weight-loss benefit. CPB 0039: many Aetna benefit plans specifically exclude coverage of weight reduction medications — check the plan booklet before anything else.
Initial BMI: BMI >= 30, OR BMI >= 27 with >= 1 weight-related comorbidity. Wegovy adolescents 12-17: BMI >= 95th percentile.
Comorbidities: At least one weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, dyslipidemia).
Lifestyle requirement: Comprehensive weight management program (behavioral modification, reduced-calorie diet, increased physical activity, continuing follow-up) for >= 6 months.
Initial authorization: Wegovy 7 · Zepbound 8 (weight) / 6 (OSA) · continuation 12
Reauthorization: Lost at least 5% of baseline body weight OR maintained the initial 5% loss. Pediatric: BMI reduction from baseline.
Step therapy: Structural, not in-policy: on standard formularies Zepbound requires documented inadequate response, intolerance, or contraindication to Wegovy (the formulary alternative) via the exception policy 6981-A.
Quantity limits: Wegovy 0.25-1 mg: 2 mL/21 days; 1.7/2.4 mg: 3 mL/21 days (1 carton/28 days). Zepbound: 2 mL/21 days, 6 mL/63 days.

Primary criteria document:aetna.com

Exceptions and appeals

Appeal deadline: 180 days
Deadline detail: 180 days internal; external review ~4 months after final adverse determination.
Exception route: ePA via CoverMyMeds/Surescripts or fax through CVS Caremark PA. Aetna Pharmacy line 1-888-792-3862. Formulary exception per policy 6981-A documentation requirements.
Turnaround: Standard PA ~3-5 business days; expedited 24-72 hours (secondary source).
Where: Per your denial letter (plan-specific).

Source:findhonestcare.com

Dated changes

Jul 1, 2025 Zepbound off standard template; Wegovy sole preferred (CVS reported >95% of members transitioned) source
Mar 10, 2026 CPB 0039 (Weight Reduction) re-reviewed source
Oct 1, 2026 Zepbound back as additional preferred on templates source

Aetna Medicaid (Aetna Better Health) runs separate state-specific criteria. If denied on a standard formulary, the Wegovy-first step is the crux: document intolerance or inadequate response to Wegovy specifically.

These are each payer's standard template. Employer plans customize them, so the same PBM can cover a drug for one employer and exclude it for another — a status here is a starting point, not your plan. A benefit exclusion is also a different fight from a PA denial. Always request your own plan's criteria in writing; you are entitled to them.