HealthRX.com · Printable coverage checklist
Aetna Mounjaro bulletin 5468-C request and renewal sheet
Note which Aetna drug list your plan uses, record the metformin history or A1C that opens a new-start request, track the stable-dose date and A1C change that renewal asks for, and keep a log of every decision.
Your Aetna plan
Drug list name your plan usesfor example Aetna Standard Plan or an employer custom list
How Mounjaro shows on that list (tier, PA, QL)
Policy number on any approval or denial letter
What Aetna's published documents say
- Bulletin 5468-C: a new start qualifies after an inadequate response, intolerance or contraindication to metformin, or with a need for combination therapy and an A1C of 7.5% or higher.[1]
- Renewal asks for a stable maintenance dose for at least 3 months and a lower A1C than at the start.[1]
- Quantity limit: 4 pens or vials per 21 days, or 12 per 63 days.[1]
- Aetna says a bulletin is only a partial, general description of benefits and is not a contract.[1]
- On the Aetna Standard Plan's October 2026 exclusions list, Victoza is not covered and Mounjaro is named among its covered alternatives.[2]
- The Aetna Standard Plan added Zepbound to its formulary under antiobesity drugs from October 1, 2026.[3]
New-start evidence
Metformin: dose, dates, and why it stopped or was not enough
Most recent A1C and datethe combination-therapy route asks for 7.5% or higher
Other diabetes medicines now taken
Renewal tracker
| Date | Mounjaro dose | A1C result | Pens dispensed | Approval end date |
|---|---|---|---|---|
Before an appeal
- Copy of the denial with the policy number and the criterion marked unmet
- Request for the full clinical review file and the criteria applied
- Prescriber letter that answers that one criterion directly
- Lab reports with dates for each A1C cited
- Pharmacy history showing metformin fills or the reason it was not used
Questions for Aetna or CVS Caremark
- Is my request reviewed under bulletin 5468-C, 5467-C, or a custom employer policy?
- How long will an approval last on my plan?
- Does my plan cover Mounjaro as preferred, and what will a 28-day fill cost?
- If my plan covers Zepbound, which criteria apply to it?
- What is the deadline and fax or portal for an appeal on my plan type?
Sources for the facts on this sheet
- Aetna, Pharmacy Clinical Policy Bulletins (Non-Medicare). GIP-GLP-1 Agonist Mounjaro PA with Limit Policy 5468-C UDR 05-2024 - Pharmacy Clinical Policy Bulletins, Aetna Non-Medicare Prescription Drug Plan. Accessed 2026-10-18. https://www.aetna.com/products/rxnonmedicare/data/2025/GIP-GLP-1_Agonist_Mounjaro_PA_with_Limit_Policy_5468-C_UDR_05-2024.html
- Aetna. 2026 Formulary Exclusions Drug List: Drugs not covered and their covered alternatives for the Aetna Standard Plan (October 2026). Accessed 2026-10-18. https://www.aetna.com/content/dam/aetna/pdfs/aetnacom/individuals-families-health-insurance/document-library/pharmacy/2026-exclusion-drug-list-aetna-standard-plan.pdf
- Aetna. Formulary Updates for Aetna Standard Plan effective October 1, 2026. Accessed 2026-10-18. https://www.aetna.com/content/dam/aetna/pdfs/aetnacom/individuals-families-health-insurance/document-library/pharmacy/SOC-for-10.01.26-Aetna-Standard-Plan.pdf
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.