Employer / Commercial Insurance
Covered with requirementsWhat 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.
MASH with Moderate to Advanced Fibrosis (F2-F3) - Wegovy Injection
All of:
- Diagnosis of noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH), formerly known as NASH, with moderate to advanced liver fibrosis (consistent with stages F2 to F3)
- Stage F2 or F3 fibrosis confirmed prior to therapy by one of: liver biopsy, VCTE, ELF score, or MRE
- Requested agent is Wegovy injection
- Patient is an adult (18 years of age or over)
- 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, hepatocellular carcinoma, hepatitis)
- Prescriber is a specialist (e.g., hepatologist, gastroenterologist) or has consulted with a specialist
Plus any one of:
- Female patient: alcohol consumption < 20 grams/day
- Male patient: alcohol consumption < 30 grams/day
Documentation to bring
- Medical records confirming diagnosis of noncirrhotic MASH
- Documentation of F2 or F3 fibrosis staging by: liver biopsy, VCTE, ELF score, or MRE (prior to therapy initiation)
- Documentation that patient does NOT have decompensated cirrhosis
- Documentation that patient does NOT have Child-Pugh Class B or C hepatic impairment
- Documentation that patient does NOT have other liver disease (e.g., Wilson's disease, hepatocellular carcinoma, hepatitis)
- Documentation of alcohol consumption level (< 20 g/day for females, < 30 g/day for males)
- Documentation of monitoring/treatment for comorbid conditions (e.g., CVD, diabetes, dyslipidemia, hypertension)
- Documentation of specialist prescriber or specialist consultation (e.g., hepatologist, gastroenterologist)
Quantity limits
- 0.25 MG/0.5 ML injection, 0.5 MG/0.5 ML injection, 1 MG/0.5 ML injection — 8 Pens per 180 days (84-day)
- 1.7 MG/0.75 ML injection, 2.4 MG/0.75 ML injection — 4 Pens per 28 days
- 7.2 MG/0.75 ML injection (Wegovy hd) — 4 Pens per 28 days
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- To renew, the plan looks for Patient must demonstrate clinical benefit with the requested agent. Fibrosis staging confirmation (liver biopsy, VCTE, ELF, or MRE) is NOT required at renewal. Alcohol consumption limits, hepatic exclusions, and specialist/consultation requirement remain 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)
- Alcohol consumption >= 20 g/day (female) or >= 30 g/day (male)
- Cirrhotic MASH (must be noncirrhotic)
Policy note: Policy specifies Wegovy INJECTION only for MASH indication — Wegovy tablets are NOT included in the MASH pathway. MASH was formerly known as nonalcoholic steatohepatitis (NASH). Alcohol limit: one standard drink contains roughly 14 grams of pure alcohol (12 oz regular beer, 5 oz wine, or 1.5 oz distilled spirits). At renewal, fibrosis staging confirmation is not re-required, but alcohol limits and hepatic exclusions remain.
Policy effective June 1, 2026 · verified June 4, 2026 · source: WY_Weight_Management_PAQL_ProgSum.pdf