Employer / Commercial Insurance
Covered with requirementsWhat you need to qualify
- Age 18 and older
- Prescribed by or in consultation with a specialist
- Confirmed MASH diagnosis by FibroScan_VCTE, MRE, and liver_biopsy, fibrosis stage F2 to F3
Qualification pathways
You can qualify through any one of these.
Noncirrhotic MASH with moderate to advanced fibrosis (F2-F3) - initial approval
All of:
- Request is for Wegovy (semaglutide) injection — NOT Wegovy HD 7.2 mg injection OR Wegovy tablets
- Used with reduced-calorie diet AND increased physical activity
- Prescribed by or in consultation with a gastroenterologist or hepatologist
- Noncirrhotic MASH diagnosis
- Moderate to advanced liver fibrosis (stages F2 to F3) confirmed by non-invasive liver disease assessment (e.g., ultrasound-based elastography, MRE) OR historical liver biopsy
Documentation to bring
- Documentation of noncirrhotic MASH diagnosis with moderate to advanced liver fibrosis (F2-F3)
- Non-invasive liver disease assessment results (e.g., ultrasound-based elastography, MRE) OR historical liver biopsy confirming F2-F3 fibrosis
- Documentation of prescribing or consulting gastroenterologist or hepatologist
Quantity limits
- 0.25 mg/0.5 mL, 0.5 mg/0.5 mL, 1 mg/0.5 mL — 2 mL (1 package of 4 pens) / 21 days; 6 mL (3 packages of 4 pens each) / 63 days (84-day)
- 1.7 mg/0.75 mL, 2.4 mg/0.75 mL — 3 mL (1 package of 4 pens) / 21 days; 9 mL (3 packages of 4 pens each) / 63 days (84-day)
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- To renew, the plan looks for Positive clinical response required: improvement in liver function such as reduction in ALT, improvement in Enhanced Liver Fibrosis (ELF) score, improvement in liver stiffness measurement (LSM) by ultrasound-based elastography or MRE. Patient must be treated with maintenance dosage based on individual treatment response and tolerability.
Not covered when
- Wegovy HD 7.2 mg injection is excluded from MASH coverage
- Wegovy tablets are excluded from MASH coverage
- Cirrhotic MASH is excluded (noncirrhotic only)
Policy note: MASH indication approved under FDA accelerated approval. Policy specifies confirmation methods as non-invasive liver disease assessment (e.g., ultrasound-based elastography, MRE) OR historical liver biopsy — no specific lookback period stated. Specialist (gastroenterologist or hepatologist) required at initial approval. Continuation does not re-require specialist attestation per the continuation criteria text. DOA is 12 months for both initial and continuation.
Policy effective April 10, 2026 · verified June 2, 2026 · source: policy-260.html