BCBS North Carolina coverage for Wegovy (Liver Disease (MASH))

Patient must have anti-obesity medication coverage benefits (criterion 7 of initial criteria; criterion 4 of continuation criteria)

What you need to qualify

• Age 18 and older
• Prescribed by or in consultation with a specialist
• Confirmed MASH diagnosis by liver_biopsy, FibroScan_VCTE, ELF_test, and MRE, fibrosis stage F2 to F3

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Documentation of MASH diagnosis
• Fibrosis staging documentation confirming F2 or F3 via one of: liver biopsy, vibration-controlled transient elastography (VCTE), enhanced liver fibrosis (ELF) score, or magnetic resonance elastography (MRE)
• Documentation confirming absence of significant alcohol consumption
• Documentation confirming absence of decompensated cirrhosis
• Documentation confirming absence of other liver disease (Wilson's disease, hepatocellular carcinoma, hepatitis, etc.)
• Documentation that prescriber is a hepatologist/gastroenterologist specialist OR has consulted with such a specialist
• Documentation that patient is not concurrently using another GLP-1 receptor agonist
• Documentation that patient is not concurrently using another weight loss medication
• Confirmation of anti-obesity medication coverage benefits

Quantity limits

• 0.25 mg/0.5 mL, 0.5 mg/0.5 mL, 1 mg/0.5 mL — 4 pens per 28 days
• 1.5 mg tablet — 1 tablet per day
• 4 mg tablet — 1 tablet per day
• 9 mg tablet — 1 tablet per day

Approval and renewal

• Initial approval: 6 months
• Renewal: every 12 months
• To renew, the plan looks for Patient must demonstrate a positive clinical response while using the medication. Patient must not have significant alcohol consumption, decompensated cirrhosis, or any other liver disease. Specialist involvement (or consultation) must continue.

Not covered when

• Significant alcohol consumption
• Decompensated cirrhosis
• Any other liver disease (e.g., Wilson's disease, hepatocellular carcinoma, hepatitis)
• Concurrent use of another GLP-1 receptor agonist
• Concurrent use of another weight loss medication

Policy note: MASH indication added January 2026. Applies to Wegovy injection (0.25mg–2.4mg) only per the criteria section structure (section c.iii). No explicit lookback periods stated for fibrosis confirmation methods. No BMI threshold is specified for this indication. Noncirrhotic MASH with F2-F3 fibrosis is the target population (per FDA labeling mirrored in policy).

Policy effective July 1, 2026 · verified July 16, 2026 · source: Pa policy