By Counterforce Health Team in Ozempic / Mounjaro (semaglutide / tirzepatide) —

How to Get Ozempic and Mounjaro Covered by Aetna CVS Health in Georgia: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Ozempic/Mounjaro Covered by Aetna CVS Health in Georgia

To get Ozempic or Mounjaro covered by Aetna CVS Health in Georgia: Your doctor must submit prior authorization showing type 2 diabetes diagnosis, recent A1c, and documented metformin trial/failure. If denied, file internal appeal within 180 days, then Georgia external review within 60 days of final denial. First step today: Verify your plan's formulary status at aetna.com/formulary and gather your A1c and medication history for your prescriber.

Table of Contents

  1. Aetna CVS Health Policy Overview
  2. Indication Requirements for Coverage
  3. Step Therapy and Medical Exceptions
  4. Quantity Limits and Renewal Rules
  5. Required Diagnostics and Documentation
  6. Specialty Pharmacy Requirements
  7. Evidence Supporting Medical Necessity
  8. Sample Medical Necessity Narrative
  9. Appeals Process in Georgia
  10. Common Denial Reasons and Solutions
  11. Cost Savings and Patient Programs
  12. FAQ

Aetna CVS Health Policy Overview

Aetna CVS Health requires prior authorization for both Ozempic (semaglutide) and Mounjaro (tirzepatide) on commercial, exchange, and Medicare plans in Georgia. These medications appear on Aetna's 2025 precertification list and are subject to step therapy protocols.

Plan Types Affected:

  • Commercial employer plans
  • Individual/family marketplace plans
  • Aetna Medicare Advantage (Part C)
  • Medicare Part D prescription coverage

CVS Caremark handles most specialty drug prior authorizations, while CVS Specialty Pharmacy manages distribution for certain high-cost medications.

Note: Policy criteria are consistent across states, but Georgia-specific appeal rights and external review processes apply to fully insured plans.

Indication Requirements for Coverage

FDA-Approved Uses

Ozempic (semaglutide):

  • Type 2 diabetes mellitus
  • Cardiovascular risk reduction in adults with T2DM and established cardiovascular disease
  • Chronic kidney disease risk reduction in T2DM (2025 indication)

Mounjaro (tirzepatide):

  • Type 2 diabetes mellitus as adjunct to diet and exercise

Coverage Restrictions

According to Aetna's Mounjaro policy:

  • Not covered for type 1 diabetes
  • Not studied in patients with history of pancreatitis
  • Weight loss under diabetes NDC codes typically denied (separate obesity policies apply)

Step Therapy and Medical Exceptions

Required First-Line Therapy

Aetna requires documented trial of metformin before approving GLP-1 or dual GIP-GLP-1 agonists unless contraindicated. Acceptable documentation includes:

  • Pharmacy claims showing 30-day metformin fill within last 180 days
  • Chart notes documenting adequate trial with insufficient response
  • Medical contraindications: advanced CKD, severe GI intolerance, documented allergy

Medical Exception Criteria

Metformin exceptions approved for:

  • eGFR <30 mL/min/1.73m² (relative contraindication)
  • Severe, persistent GI side effects despite dose adjustment
  • Documented hypersensitivity/allergy
  • Drug interactions with contraindicated medications

Combination therapy qualification:

  • A1c ≥7.5% despite metformin therapy
  • Clinical need for additional glycemic control per ADA guidelines

Quantity Limits and Renewal Rules

Standard Quantity Limits

Per Aetna's policy:

Medication Quantity Limit Days Supply
Mounjaro 4 pens (2mL) or 12 pens (6mL) 21 or 63 days
Ozempic Plan-specific Typically 28-day cycles

Renewal Requirements

Initial authorization: Up to 6 months Continuation criteria:

  • Stable maintenance dose for ≥3 months
  • Documented A1c reduction since starting therapy
  • Ongoing diabetes management needs

Required Diagnostics and Documentation

Essential Lab Values

Recent A1c (within 3-6 months):

  • Document baseline and current values
  • Show inadequate control on current regimen
  • Target: Generally A1c ≥7.0% for coverage consideration

Additional helpful labs:

  • Comprehensive metabolic panel (eGFR for metformin clearance)
  • Lipid panel (if CV risk reduction indication)
  • Microalbumin (if kidney protection indication)

Clinical Documentation Checklist

✓ ICD-10 diagnosis codes (E11.xx for T2DM)
✓ Height, weight, BMI calculations
✓ Prior medication trials with dates and outcomes
✓ Current diabetes medications and dosing
✓ Diabetes complications or comorbidities
✓ Treatment goals and monitoring plan

Specialty Pharmacy Requirements

CVS Specialty Routing

Some Aetna plans require Ozempic and Mounjaro to be dispensed through CVS Specialty Pharmacy rather than retail pharmacies. Check your specific plan's pharmacy network requirements.

CVS Specialty contact: 1-800-237-2767

Site of Care Considerations

  • Most GLP-1 medications are self-administered subcutaneous injections
  • No special infusion site requirements
  • Patient education on injection technique typically provided by specialty pharmacy

Evidence Supporting Medical Necessity

Clinical Guidelines to Reference

American Diabetes Association (ADA) Standards:

  • GLP-1 receptor agonists as second-line therapy after metformin
  • Cardiovascular and kidney benefits in high-risk patients
  • Weight management advantages in overweight/obese patients

Key Evidence Points:

  • FDA labeling for approved indications
  • Peer-reviewed studies showing superiority over older agents
  • Contraindications to alternative therapies
  • Patient-specific factors requiring this medication class
Clinician Corner: When writing medical necessity letters, cite specific ADA recommendations and FDA labeling. Include patient-specific contraindications to formulary alternatives and document why step therapy was inadequate or inappropriate.

Sample Medical Necessity Narrative

"Patient is a [age]-year-old with type 2 diabetes mellitus (E11.9) with current A1c of [value]% despite metformin [dose] daily for [duration]. Metformin was trialed at maximum tolerated dose with inadequate glycemic response [or: discontinued due to severe GI intolerance documented on [date]]. Patient requires additional glycemic control to reach ADA-recommended target A1c <7.0% and reduce cardiovascular risk. Mounjaro/Ozempic is medically necessary as FDA-approved second-line therapy per ADA guidelines, with proven efficacy in similar patients and favorable safety profile for this individual."

Appeals Process in Georgia

Internal Appeal Timeline

Aetna internal appeals: File within 180 days of denial

  • Standard decision: 30-45 days
  • Expedited appeals: 72 hours when delay jeopardizes health
  • Submit via Aetna provider portal or fax

Georgia External Review

If internal appeal is denied, Georgia residents can request external review through the Georgia Department of Insurance:

Key deadlines:

  • 60 days from final internal denial to request external review
  • Free for consumers
  • Independent medical review by specialists
  • Binding decision on Aetna

Contact Georgia DOI:

Expedited Review Criteria

Request urgent review when delay would "seriously jeopardize life or health." For diabetes medications, document:

  • Risk of DKA, severe hyperglycemia, or hypoglycemia
  • Recent ER visits or hospitalizations
  • Failed alternatives creating dangerous gaps in therapy

Counterforce Health specializes in transforming insurance denials into successful appeals by analyzing payer policies and crafting evidence-backed rebuttals. Our platform helps patients and providers navigate complex prior authorization requirements like those outlined above, increasing approval rates through targeted documentation strategies.

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
No metformin trial documented Provide pharmacy claims or chart notes 30-day fill within 180 days OR contraindication
Insufficient A1c documentation Submit recent lab results A1c within 3-6 months showing inadequate control
Non-formulary drug Request formulary exception Medical necessity letter with alternatives tried
Quantity limit exceeded Justify higher dose/frequency Clinical rationale for titration schedule
Experimental/investigational Cite FDA approval and guidelines FDA labeling, ADA recommendations

Cost Savings and Patient Programs

Manufacturer Programs

Ozempic: Novo Nordisk patient assistance

  • Commercial insurance: Up to $150 off monthly copay
  • Uninsured: Patient assistance program available

Mounjaro: Lilly Diabetes Solution Center

  • Savings card: $25 monthly copay for commercially insured
  • Patient assistance for qualifying uninsured patients
Note: Manufacturer copay assistance not available for Medicare, Medicaid, or other government insurance.

FAQ

Q: How long does Aetna prior authorization take in Georgia? A: Standard PA decisions typically take 30-45 days for commercial plans, 72 hours for Medicare Part D. Expedited reviews can be completed in 72 hours when medically urgent.

Q: What if Ozempic or Mounjaro is non-formulary on my plan? A: Request a formulary exception through your prescriber. Include medical necessity documentation showing why formulary alternatives are inappropriate or have failed.

Q: Can I appeal if I've tried metformin in another state? A: Yes, pharmacy claims or medical records from any location are acceptable documentation of prior therapy trials.

Q: Does step therapy apply if I'm switching from another GLP-1? A: Generally no. If you're already stable on a GLP-1 medication, switching within the class typically doesn't require repeating step therapy.

Q: How do I request an expedited appeal with Aetna? A: Your prescriber should mark the appeal "EXPEDITED" and document how delay would jeopardize your health. Include specific medical risks like DKA or hospitalization.

Q: What's the difference between internal and external review? A: Internal appeals are reviewed by Aetna. External review is conducted by independent physicians through Georgia's insurance department and is binding on Aetna.

For complex cases requiring detailed appeal strategies, Counterforce Health provides specialized support in crafting evidence-based appeals that align with specific payer criteria and increase approval success rates.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and may change. Always verify current requirements with your specific Aetna plan and consult healthcare providers for medical decisions. For assistance with appeals or coverage questions, contact the Georgia Department of Insurance Consumer Services at 1-800-656-2298.

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