Applies to Employer plans.
Depends on your plan's benefitPatient must have anti-obesity medication coverage benefits (criterion 7 of initial criteria; criterion 4 of continuation criteria)
Qualification pathways
You can qualify through any one of these.
MASH with moderate-to-advanced fibrosis (F2-F3)
All of:
- Patient is 18 years of age or older
- Diagnosis of Metabolic Dysfunction-Associated Steatohepatitis (MASH)
- Moderate to advanced liver fibrosis consistent with fibrosis stage F2 or F3 confirmed by one of: liver biopsy, VCTE, ELF score, or MRE
- No significant alcohol consumption
- No decompensated cirrhosis
- No other liver disease (e.g., Wilson's disease, hepatocellular carcinoma, hepatitis)
- Prescriber is a specialist (e.g., hepatologist, gastroenterologist) OR prescriber has consulted with a specialist
- Requested medication will NOT be used concurrently with another GLP-1 receptor agonist
- Requested medication will NOT be used concurrently with another weight loss medication
- Patient has anti-obesity medication coverage benefits
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
- Renewal: 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: BCBS North Carolina Employer / Commercial Insurance prior authorization policy · View policy document (PDF)