Employer / Commercial Insurance
Covered with requirementsWhat you need to qualify
- Age 18 and older
- Confirmed MASH diagnosis by FIB-4, FibroScan_VCTE, MRE, ELF_test, 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)
All of:
- Adult patient (>= 18 years)
- Diagnosis of noncirrhotic MASH (formerly NASH)
- Fibrosis stage F2 or F3 confirmed by non-invasive testing or biopsy
- No cirrhosis
Plus any one of:
- FIB-4 score indicating moderate/high risk (< 1.30 low risk; 1.30–2.67 indeterminate; > 2.67 high risk) with confirmatory testing as needed
- VCTE/FibroScan elastography confirming F2-F3 fibrosis
- MRE confirming F2-F3 fibrosis
- ELF test result indicating significant fibrosis
- Liver biopsy confirming MASH with F2-F3 fibrosis
Documentation to bring
- Diagnosis of noncirrhotic MASH (formerly NASH/MASLD)
- Confirmation of fibrosis stage F2 or F3 via non-invasive testing (FIB-4, ELF, VCTE/FibroScan, or MRE) or liver biopsy
- FIB-4 as primary risk stratification with secondary confirmatory elastography or ELF if FIB-4 is indeterminate
- Confirmation of absence of cirrhosis
Not covered when
- Cirrhotic MASH is excluded (FDA indication limited to noncirrhotic MASH)
- Concomitant use with other semaglutide-containing products not recommended
- Concomitant use with any other GLP-1 receptor agonist not recommended
- Pregnancy
Policy note: FDA indication for MASH is limited to Wegovy subcutaneous injection (not the tablet formulation listed separately). Fibrosis stage F2-F3 required per both FDA label and the NASH trial (NCT04822181) referenced in the document. The document outlines a two-step non-invasive testing approach: Step 1 FIB-4 (low risk < 1.30, indeterminate 1.30–2.67, high risk > 2.67; for patients > 65 years, higher cutoff > 2.0 for rule-in), Step 2 ELF and/or elastography (VCTE) with specific cutpoints referenced (ELF < 7.7 low risk, 7.7–9.8 intermediate, >= 9.8 high risk; VCTE < 8 kPa low risk, 8–12 kPa indeterminate, > 12 kPa high risk/advanced fibrosis). MRE also noted as an option. Lookback periods for testing are not explicitly specified in the PA criteria section of this document. Alcohol abstinence recommended in advanced fibrosis but no specific gram limits stated as PA criteria. This is a Program Summary document; specific PA approval criteria thresholds may be in a separate criteria document.
Policy effective April 20, 2026 · verified June 2, 2026 · source: ALBP_Weight_Management_PAQL_ProgSum.pdf