Aetna (CVS Health)

Insurer (Caremark-administered) · updated September 16, 2026

Coverage right now

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

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). Policy 6981-A is an alternatives notice, not a route back to Zepbound: it names Wegovy the primary formulary alternative and Mounjaro the secondary, and the only authorization it grants after documented inadequate response, intolerance or contraindication to Wegovy is for Mounjaro. The 2.5, 5, 7.5 and 10 mg single-dose vials sit outside the policy entirely — it excludes them by strength as covered under the LillyDirect manufacturer program. 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 these rules come to in dollars — every dose, priced under this coverage:

Foundayo 0.8 mg 2.5 mg 5.5 mg 9 mg 14.5 mg 17.2 mg
Wegovy 0.25 mg 0.5 mg 1 mg 1.7 mg 2.4 mg 7.2 mg
Wegovy® tablets 1.5 mg 4 mg 9 mg 25 mg
Zepbound 2.5 mg 5 mg 7.5 mg 10 mg 12.5 mg 15 mg

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 rather than in-policy, and scoped to the exclusion: THROUGH SEPTEMBER 30, 2026, a Zepbound request on a standard formulary was answered by exception policy 6981-A, which offered Wegovy first and, on documented inadequate response, intolerance or contraindication to Wegovy, approved Mounjaro rather than Zepbound. Zepbound returns as an additional preferred option on Caremark-administered templates on October 1, 2026, and Aetna has published no post-return criteria, so what governs a Zepbound request from that date is not documented — ask the plan in writing rather than assuming either the old exception route or none.
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. For a denial dated on or before September 30, 2026, the Wegovy-first step was the crux: document intolerance or inadequate response to Wegovy specifically — and note that what 6981-A then approved was Mounjaro, not Zepbound. That advice expires with the exclusion. From October 1, 2026 Zepbound is an additional preferred option on Caremark-administered templates, and no Aetna criteria document for the returned drug has been published, so a request made from that date should start by asking the plan for its current Zepbound criteria in writing. On the wegovy-oral citation: managedhealthcareexecutive.com began serving this environment a Cloudflare challenge on 2026-09-11 and refused curl, WebFetch and a real browser alike, so that row's source cannot be opened here and its claim has only been re-confirmed through host-scoped search. It is trade press behind an already-MEDIUM row, and every Aetna-published document this file cites was read in full on that date.

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.