Applies to Employer and ACA Marketplace plans.
Covered with requirementsQualification 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
- Renewal: 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 Prog Sum · View policy document (PDF)