Employer / Commercial Insurance
Covered with requirementsWhat you need to qualify
- Age 18 and older
- Confirmed MASH diagnosis, fibrosis stage F2 to F3
Qualification pathways
You can qualify through any one of these.
MASH with Moderate to Advanced Liver Fibrosis (F2-F3)
All of:
- Diagnosis of noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH)
- Moderate to advanced liver fibrosis consistent with stages F2 to F3
- Adult (age >= 18 years old)
- Current baseline weight documented
- Used in combination with reduced calorie diet and increased physical activity
- Physician attestation that member will participate in lifestyle modifications
- Not to be used in combination with other weight loss products
- Cannot be used in combination with other GLP-1 agonist-containing products
Documentation to bring
- Documentation of diagnosis of noncirrhotic MASH with moderate to advanced liver fibrosis (F2 to F3)
- Documentation of current baseline weight
- Physician attestation of member participation in lifestyle modifications (reduced calorie diet and increased physical activity)
- Attestation that medication will not be combined with other weight loss products
- Attestation that medication will not be combined with other GLP-1 agonist-containing products
- For continuation: Physician attestation of current weight submitted to plan
- For continuation: Attestation of continued active participation in lifestyle modifications
- For continuation: BMI >= 18.5 kg/m2
Approval and renewal
- Initial approval: 12 months
- To renew, the plan looks for For MASH continuation: Physician attestation of current weight submitted to plan, attestation of continued active participation in lifestyle modifications that support weight loss, BMI >= 18.5 kg/m2. No explicit weight loss percentage threshold required for MASH continuation (unlike obesity/CV pathways which require 5% weight loss).
Not covered when
- Cirrhotic MASH is excluded (noncirrhotic only)
- Cannot be used in combination with other weight loss products
- Cannot be used in combination with other GLP-1 agonist-containing products
Policy note: The policy specifies noncirrhotic MASH only, with fibrosis stages F2 to F3. No specific fibrosis confirmation methods (biopsy, FibroScan, FIB-4, MRE, ELF) are specified in the policy. No lookback periods for diagnostic tests are specified. Continuation criteria for MASH differ from obesity/CV pathways — no explicit weight loss percentage threshold is required; instead physician attestation of current weight and continued lifestyle modifications are required along with BMI >= 18.5 kg/m2.
Policy effective June 1, 2026 · verified June 2, 2026 · source: prior-authorization-and-step-therapy-guidelines.pdf