Employer / Commercial Insurance
Covered with requirementsWhat you need to qualify
- Age 18 and older
- Confirmed MASH diagnosis by liver_biopsy, FibroScan_VCTE, transient_elastography, shear_wave_elastography, and MRE, fibrosis stage F2 to F3
Qualification pathways
You can qualify through any one of these.
Initial Authorization - MASH (Wegovy injection only)
All of:
- Patient is 18 years of age or older
- Confirmed and documented diagnosis of MASH with moderate to advanced liver fibrosis (stages F2 to F3) - NOT cirrhosis (F4) and NOT hepatic decompensation
- Patient does NOT have cirrhosis (F4) or hepatic decompensation
- Patient does NOT have Type I Diabetes Mellitus diagnosis
- Patient does NOT have acute pancreatitis within the last 180 days
- Patient has no history or current evidence of chronic pancreatitis
- Patient does NOT have documented causes of chronic liver disease other than MASLD
- Patient has no history or current evidence of hepatocellular carcinoma
- Patient does NOT have personal history of, or first-degree relative with, medullary thyroid carcinoma or personal history of MEN 2
- Patient does NOT have excessive alcohol use within past 3 months (defined as >20 g/day for women and >30 g/day for men)
- Patient's concomitant related conditions (dyslipidemia, Type II diabetes, hypertension) are managed according to standard of care
- Medication will be used in conjunction with lifestyle interventions (diet and exercise)
- Patient will NOT use medication in combination with other GLP-1 Agonists or GLP-1/GIP Receptor Agonists
- Patient will NOT use medication in combination with Rezdiffra (resmetirom tablets)
Plus any one of:
- Liver biopsy within the last 12 months confirming MASH with F2-F3 fibrosis AND (if biopsy used) NAFLD Activity Score (NAS) >= 4 with score > 1 in ALL of: steatosis, hepatocyte ballooning, and lobular inflammation
- Imaging-based elastography within the last 6 months confirming F2-F3 fibrosis (vibration-controlled elastography/FibroScan, transient elastography, shear wave elastography, or magnetic resonance elastography)
Continuation Authorization - MASH (Wegovy injection only)
All of:
- Patient has an initial authorization for the requested medication
- Patient has documentation of a diagnosis of MASH with moderate to advanced liver fibrosis (stages F2 to F3)
- Patient has NOT progressed to stage F4 (cirrhosis)
- Patient has been adherent to treatment with Wegovy
- Patient is experiencing a positive clinical response (stabilization and/or improvement in fibrosis and/or MASH)
- Patient's concomitant related conditions (dyslipidemia, Type II diabetes, hypertension) are managed according to standard of care
- Patient does NOT have excessive alcohol use within past 3 months (>20 g/day for women and >30 g/day for men)
- Patient is tolerating a maintenance dose of 2.4 mg once weekly
- Patient will NOT use medication in combination with other GLP-1 Agonists or GLP-1/GIP Receptor Agonists
- Patient will NOT use medication in combination with Rezdiffra (resmetirom tablets)
Documentation to bring
- Documentation of patient age >= 18 years
- Confirmed and documented diagnosis of MASH with moderate to advanced liver fibrosis (F2 to F3 fibrosis)
- Liver biopsy report within the last 12 months confirming MASH with F2-F3 fibrosis (if biopsy used as confirmation method), OR imaging-based elastography report within the last 6 months (FibroScan/VCTE, transient elastography, shear wave elastography, or MRE) confirming F2-F3 fibrosis
- If liver biopsy used: NAFLD Activity Score (NAS) >= 4 documented, with score > 1 in ALL of steatosis, hepatocyte ballooning, and lobular inflammation
- Documentation confirming no cirrhosis (F4) or hepatic decompensation
- Documentation confirming no Type I Diabetes Mellitus diagnosis
- Documentation confirming no acute pancreatitis within the last 180 days
- Documentation confirming no history or current evidence of chronic pancreatitis
- Documentation confirming no other documented causes of chronic liver disease other than MASLD
- Documentation confirming no history or current evidence of hepatocellular carcinoma
- Documentation confirming no personal history or first-degree family history of medullary thyroid carcinoma or MEN 2
- Documentation confirming patient does not have excessive alcohol use within past 3 months (>20 g/day women, >30 g/day men)
- Documentation that comorbid conditions (dyslipidemia, T2DM if present, hypertension) are managed per standard of care
- Prescriber attestation that medication will be used in conjunction with lifestyle interventions (diet and exercise)
- Prescriber attestation that medication will NOT be used in combination with other GLP-1 Agonists or GLP-1/GIP Receptor Agonists
- Prescriber attestation that medication will NOT be used in combination with Rezdiffra (resmetirom tablets)
- For continuation: Documentation of positive clinical response (stabilization and/or improvement in fibrosis and/or MASH)
- For continuation: Documentation confirming adherence to treatment
- For continuation: Documentation that patient is tolerating maintenance dose of 2.4 mg once weekly
- For continuation: Documentation confirming patient has not progressed to F4 cirrhosis
Approval and renewal
- To renew, the plan looks for For continuation: patient must be experiencing a positive clinical response as evidenced by documentation of stabilization and/or improvement in fibrosis and/or MASH (e.g., improved steatosis, improved fibrosis, improvement in fibrosis score, lack of disease progression). Patient must not have progressed to stage F4 (cirrhosis). Patient must have been adherent to treatment. Patient must be tolerating maintenance dose of 2.4 mg once weekly. Comorbid conditions (dyslipidemia, T2DM, hypertension) must be managed per standard of care. Alcohol limits continue to apply (within past 3 months). Initial diagnosis confirmation testing (biopsy/imaging) is NOT re-required at continuation — only documentation of MASH F2-F3 diagnosis is needed and staying on a maintenance dose of at least 2.4 mg.
Not covered when
- Cirrhosis (F4) or hepatic decompensation (investigational for contracts including obesity medications; not covered for contracts excluding obesity medications)
- Acute pancreatitis within the last 180 days
- History or current evidence of chronic pancreatitis
- Documented causes of chronic liver disease other than MASLD
- History or current evidence of hepatocellular carcinoma
- Personal history of medullary thyroid carcinoma
- First-degree relative with medullary thyroid carcinoma
- Personal history of MEN 2
- Excessive alcohol use within past 3 months (>20 g/day for women or >30 g/day for men)
- Concomitant use with Rezdiffra (resmetirom tablets) - investigational
- Concomitant use with other GLP-1 Agonists or GLP-1/GIP Receptor Agonists - investigational
- Wegovy TABLET formulation for MASH - explicitly not covered
- Pediatric patients (age < 18) - investigational
- Use without lifestyle interventions (diet and exercise) - investigational
- Absence of confirmed MASH F2-F3 diagnosis (investigational for contracts including obesity medications; not covered for contracts excluding obesity medications)
- Type 1 diabetes
Policy note: IMPORTANT: Only Wegovy injection is covered for MASH. Wegovy tablet for MASH is explicitly stated as not covered. The policy requires fibrosis staging F2 to F3 only — F1 and below are not covered, and F4 (cirrhosis) is explicitly excluded. Confirmation requires either liver biopsy within 12 months OR imaging-based elastography (specifically: FibroScan/VCTE, transient elastography, shear wave elastography, or MRE) within 6 months. Note that FIB-4 and ELF (serum/blood-based tests) are NOT accepted as confirmation methods per this policy — only biopsy or imaging elastography. If biopsy is used, NAS >= 4 with score > 1 in all three components (steatosis, hepatocyte ballooning, lobular inflammation) is required. Type I DM is excluded (investigational); Type II DM is NOT excluded but must be managed per standard of care. Alcohol limits: >20 g/day for women and >30 g/day for men within past 3 months is an exclusion. Concomitant Rezdiffra use is investigational. For contracts including obesity medication coverage, the MASH F2-F3 diagnosis requirement is an additional company requirement; for contracts excluding obesity medication coverage, absence of confirmed diagnosis results in not covered determination.
Policy effective May 1, 2026 · verified June 2, 2026 · source: 00886%2020240812%20Wegovy%20semaglutideaccessible%20pdf.pdf