Applies to Employer plans.
Depends on your plan's benefitExpanded indications must NOT be restricted from coverage under the patient's pharmacy benefit.
Qualification pathways
You can qualify through any one of these.
MASH with F2-F3 Fibrosis — Initial Approval
All of:
- Expanded indications are NOT restricted from coverage under the patient's pharmacy benefit
- Diagnosis of noncirrhotic MASH (formerly NASH) with moderate to advanced liver fibrosis (stages F2 to F3)
- Requested agent is Wegovy injection
- Patient is an adult (18 years of age or over)
- Stage F2 or F3 fibrosis confirmed by one of: liver biopsy, VCTE (e.g., FibroScan), ELF score, or MRE (prior to therapy)
- Patient is being monitored and/or treated for any comorbid conditions (e.g., cardiovascular disease, diabetes, dyslipidemia, hypertension)
- Patient does NOT have decompensated cirrhosis
- Patient does NOT have moderate to severe hepatic impairment (Child-Pugh Class B or C)
- Patient does NOT have any other liver disease (e.g., Wilson's disease, HCC, hepatitis)
- Prescriber is a specialist (e.g., hepatologist, gastroenterologist) or has consulted with a specialist
- Patient will NOT use the requested agent in combination with another weight loss agent
- Patient is currently on and will continue weight management regimen
- Patient will NOT use the requested agent in combination with another GLP-1 receptor agonist
- Patient does NOT have any FDA labeled contraindications
- Patient has tried and failed at least three formulary alternatives OR prescriber indicates alternatives are contraindicated, likely less effective, or likely to cause adverse reaction
Plus any one of:
- Female patient with alcohol consumption less than 20 grams/day
- Male patient with alcohol consumption less than 30 grams/day
Documentation to bring
- Medical records documenting diagnosis of noncirrhotic MASH with fibrosis stages F2 or F3
- Documentation of fibrosis staging confirmed by liver biopsy, VCTE (FibroScan), ELF score, or MRE (obtained prior to therapy initiation)
- Documentation of alcohol consumption (< 20 g/day for females; < 30 g/day for males)
- Documentation of monitoring/treatment for comorbid conditions (CVD, diabetes, dyslipidemia, hypertension)
- Documentation ruling out decompensated cirrhosis, Child-Pugh Class B or C hepatic impairment, and other liver diseases (Wilson's disease, HCC, hepatitis)
- Documentation of specialist involvement (hepatologist or gastroenterologist) or consultation
- Documentation of formulary alternatives tried and failed (at least 3), or clinical reason alternatives are contraindicated/less effective/harmful
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- Renewal: At renewal: patient must have clinical benefit with the requested agent. Alcohol limits (< 20 g/day female, < 30 g/day male) are re-verified. Exclusions for decompensated cirrhosis, Child-Pugh B/C, and other liver disease are re-verified. Specialist requirement is re-verified. Fibrosis staging confirmation (liver biopsy/VCTE/ELF/MRE) is NOT re-required at renewal.
Not covered when
- Decompensated cirrhosis
- Moderate to severe hepatic impairment (Child-Pugh Class B or C)
- Any other liver disease (e.g., Wilson's disease, hepatocellular carcinoma, hepatitis)
- Co-administration with another weight loss agent
- Co-administration with another GLP-1 receptor agonist
- Any FDA labeled contraindications
- Alcohol consumption ≥ 20 g/day (female) or ≥ 30 g/day (male)
Policy note: The MASH indication is an expanded indication. Fibrosis must be stage F2 or F3 (noncirrhotic). Fibrosis confirmation methods accepted: liver biopsy, VCTE (FibroScan), ELF score, or MRE — no lookback period explicitly stated in the policy. The policy does not explicitly state a FIB-4 score as a standalone qualifying confirmation method (though it is discussed in the clinical rationale). The policy requires monitoring/treatment of comorbidities. Alcohol limits align with MASLD definition: < 20 g/day female, < 30 g/day male. Managed by Prime Therapeutics.
Policy effective April 1, 2026 · verified June 5, 2026 · source: BCBS Minnesota Employer / Commercial Insurance prior authorization policy · View policy document (PDF)