Employer / Commercial Insurance
Covered with requirementsWhat you need to qualify
- Age 18 and older
- BMI of 30 or higher
- 6 months of a documented diet and exercise program
- Prescribed by or in consultation with a specialist
- Confirmed MASH diagnosis by liver_biopsy, FibroScan_VCTE, ELF_test, and FIB-4, fibrosis stage F2 to F3
- Lab results confirming eligibility
Qualification pathways
You can qualify through any one of these.
Initial Approval: Wegovy for MASH
All of:
- Age >= 18 years
- Diagnosis of noncirrhotic MASH with moderate to advanced liver fibrosis (F2 to F3)
- At least THREE of the five metabolic risk factors (large waist circumference or BMI >= 30; TG >= 150 mg/dL or on specific treatment; low HDL or on specific treatment; BP >= 140/90 mmHg on two occasions or on treatment; diagnosis of T2DM)
- Evidence of liver steatosis (> 5% by imaging or histology) with at least one cardiometabolic risk factor
- Evidence of liver inflammation and hepatocellular injury (lobar inflammation and ballooning injury to hepatocytes)
- No other causes of steatotic liver disease
- Alcohol consumption < 20 g daily for females and < 30 g daily for males
- Does NOT have Stage 4 fibrosis (cirrhosis)
- Will be used as adjunct to program supporting reduced calorie diet (>= 500 kcal/day) and >= 150 min/week activity aiming for 7-10% weight loss
- Prescribed by or in consultation with a Gastroenterologist or Hepatologist
- Failure, contraindication, or intolerance to THREE generic equivalents (if available) for at least 3 months each
- No personal or family history of medullary thyroid carcinoma or MEN2
- No prior serious hypersensitivity reaction to semaglutide
- No concomitant use of GLP-1 receptor agonists or GIP/GLP-1 agonists
- No chronic pancreatitis or recent (within 180 days) acute pancreatitis
- No severe gastroparesis
- Not pregnant (if of childbearing potential)
Plus any one of:
- Liver biopsy within 2 years showing Stage 2 or 3 fibrosis with NASH/MASH (no significant weight change > 5% or use of medication that might affect NAS or fibrosis stage)
- FibroScan with transient elastography within 3 months: >= 8.5 kPa AND controlled attenuation parameter >= 280 dB/m
- Biochemical fibrosis test: PRO-C3 > 14 ng/mL OR ELF score >= 9
- Combination of imaging (VCTE, ELF) and serologic tests (FIB-4 index)
Continuation/Renewal: Wegovy for MASH
All of:
- Confirmed diagnosis of noncirrhotic MASH
- Adherence to medication and lifestyle changes aiming for 7-10% weight loss
- Continues to be seen by physician specializing in diagnosis or in consultation with a Gastroenterologist or Hepatologist
- Failure, contraindication, or intolerance to THREE generic equivalents for at least 3 months each
- No personal or family history of medullary thyroid carcinoma or MEN2
- No concomitant use of GLP-1 receptor agonists or GIP/GLP-1 agonists
- No acute or chronic pancreatitis
- No severe gastroparesis
- No sustained increase in resting heart rate
Plus any one of:
- Resolution of steatohepatitis with >= 2-point NAS reduction without worsening fibrosis (absence of ballooning [score=0] AND absence or mild lobular inflammation [score=0-1] AND no fibrosis progression >= 1 stage)
- At least one stage improvement in fibrosis without worsening NAS
- Stabilization of fibrosis by blood tests (LFTs) and non-invasive assessments
Documentation to bring
- Completed prior authorization request form
- Chart notes documenting diagnosis of noncirrhotic MASH with F2-F3 fibrosis
- Documentation of at least THREE qualifying metabolic risk factors
- ONE of the following fibrosis confirmation documents: liver biopsy report within 2 years showing Stage 2-3 fibrosis with MASH; OR FibroScan/VCTE result within 3 months (>= 8.5 kPa and CAP >= 280 dB/m); OR biochemical fibrosis test results (PRO-C3 > 14 ng/mL or ELF >= 9); OR combination of imaging and serologic tests (VCTE/ELF + FIB-4)
- Lab results including lipids and liver function tests (LFTs)
- Imaging or biopsy reports documenting liver steatosis > 5%
- Documentation of liver inflammation and hepatocellular injury (ballooning on biopsy/pathology)
- Documentation of current body weight
- Alcohol consumption history confirming < 20 g/day (females) or < 30 g/day (males)
- Documentation confirming absence of Stage 4 fibrosis (cirrhosis)
- Documentation of failure, contraindication, or intolerance to three generic equivalents for at least 3 months each
- For renewal: LFTs and non-invasive fibrosis assessment (imaging, biochemical) documenting clinical response
- For renewal: supporting clinical documentation of weight and adherence to lifestyle program
- For renewal: lab values confirming safe continued use
Approval and renewal
- Initial approval: 6 months
- Renewal: every 12 months
- To renew, the plan looks for At renewal, patient must show ONE of: (1) Resolution of steatohepatitis with >= 2-point reduction in NAS without worsening fibrosis (demonstrated by both absence of ballooning [score=0] AND absence or mild lobular inflammation [score=0-1], plus no progression >= 1 fibrosis stage); OR (2) At least one stage improvement in fibrosis without worsening NAS; OR (3) Stabilization of fibrosis by blood tests (LFTs) and non-invasive assessments. Adherence to medication and lifestyle changes aiming for 7-10% weight loss is also required. Brand-specific criteria (3 generic equivalent failures) re-checked at renewal. Initial MASH fibrosis staging criteria (F2-F3, metabolic risk factors, alcohol limits) are NOT re-verified at continuation — only clinical response is assessed.
Not covered when
- Stage 4 fibrosis (cirrhosis) — noncirrhotic MASH only
- Other causes of steatotic liver disease (drug-induced, monogenic, alcohol-induced, cryptogenic)
- Alcohol consumption >= 20 g/day for females or >= 30 g/day for males
- Personal or family history of medullary thyroid carcinoma or MEN2
- Prior serious hypersensitivity reaction to semaglutide
- Concomitant use of GLP-1 receptor agonists or GIP/GLP-1 agonists
- Chronic pancreatitis or recent (within 180 days) acute pancreatitis
- Severe gastroparesis
- Sustained increase in resting heart rate (continuation only)
- Pregnancy
Policy note: This PCG applies to Commercial and/or Marketplace plans. It does NOT apply to Federal Employee Program, Medicare Advantage, Medicaid, or out-of-state BCBS plans. Metabolic risk factors (need 3 of 5): (1) large waist circumference (men > 94 cm / women > 80 cm) OR BMI >= 30 kg/m2; (2) TG >= 150 mg/dL or on specific treatment; (3) HDL < 40 mg/dL (males) or < 50 mg/dL (females) or on specific treatment; (4) BP >= 140/90 mmHg on two occasions or on treatment; (5) T2DM diagnosis. Liver biopsy lookback is 2 years (24 months), with no significant weight change > 5% and no medication that might affect NAS or fibrosis stage. FibroScan/VCTE lookback is 3 months. No explicit lookback period stated for biochemical tests (PRO-C3, ELF) or FIB-4 combination approach. The MASH indication is approved under FDA accelerated approval. Brand-specific criteria require failure, contraindication, or intolerance to THREE generic equivalents (if available) for at least 3 months each. Manufacturer samples/assistance not accepted for continuation of therapy. Initial approval is 6 months or end of plan year; continuation is 12 months or end of plan year. Diabetes (T2DM) is listed as a qualifying metabolic risk factor, so T2DM is NOT excluded for this indication.
Policy effective May 16, 2024 · verified June 2, 2026 · source: Download