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, MRE, and ELF_test, fibrosis stage F2 to F3
Qualification pathways
You can qualify through any one of these.
Initial Approval - MASH/NASH with F2-F3 Fibrosis
All of:
- Patient is >= 18 years of age
- Patient does not have cirrhosis (F4)
- Patient has stage F2 or F3 fibrosis confirmed by an accepted diagnostic test prior to initiating treatment [documentation required]
- Patient has one or more metabolic risk factors managed per standard of care (central obesity, hypertriglyceridemia, reduced HDL-C, hypertension, or elevated fasting plasma glucose/diabetes/pre-diabetes)
- Medication will be used in combination with appropriate diet and exercise therapy
- Medication prescribed by or in consultation with an endocrinologist, gastroenterologist, or hepatologist
Plus any one of:
- Liver biopsy within 3 years preceding treatment showing F2 or F3 fibrosis [documentation required]
- VCTE within 6 months preceding treatment showing F2 or F3 fibrosis [documentation required]
- MRE within 6 months preceding treatment showing F2 or F3 fibrosis [documentation required]
- ELF test within 6 months preceding treatment with score >= 9.2 to <= 10.5 [documentation required]
Initial Approval - MASH/NASH Alcohol Limit (Female)
All of:
- Female patient: alcohol consumption < 20 grams/day
Initial Approval - MASH/NASH Alcohol Limit (Male)
All of:
- Male patient: alcohol consumption < 30 grams/day
Continuation - MASH/NASH (Year 2+)
All of:
- Patient has completed >= 1 year of therapy with Wegovy injection, Wegovy HD injection, and/or Wegovy tablet
- Prescriber attests patient has not had worsening of fibrosis or MASH/NASH
- Prescriber attests patient does not have cirrhosis (F4)
- Prescriber attests metabolic risk factors are managed per standard of care
- Medication will be used in combination with appropriate diet and exercise therapy
- Medication prescribed by or in consultation with an endocrinologist, gastroenterologist, or hepatologist
Plus any one of:
- Female patient: alcohol consumption < 20 grams/day
- Male patient: alcohol consumption < 30 grams/day
Documentation to bring
- Documentation of stage F2 or F3 fibrosis prior to treatment initiation [documentation required]
- Liver biopsy report within 3 years preceding treatment (if biopsy used for staging) [documentation required]
- VCTE results within 6 months preceding treatment (if VCTE used for staging) [documentation required]
- MRE results within 6 months preceding treatment (if MRE used for staging) [documentation required]
- ELF test result within 6 months preceding treatment with score >= 9.2 to <= 10.5 (if ELF used for staging) [documentation required]
- Prescriber attestation of one or more metabolic risk factors managed per standard of care
- Prescriber attestation of alcohol consumption limits (female < 20 g/day; male < 30 g/day)
- Documentation that medication is prescribed by or in consultation with endocrinologist, gastroenterologist, or hepatologist
- Confirmation patient does not have cirrhosis (F4)
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- To renew, the plan looks for Continuation requires: patient has completed >= 1 year of therapy; prescriber attests no worsening of fibrosis or MASH/NASH; no cirrhosis (F4); metabolic risk factors managed per standard of care; alcohol limits maintained; diet and exercise ongoing; specialist prescribing/consultation. Fibrosis staging documentation NOT re-required at continuation. ELF score, biopsy, VCTE, or MRE documentation NOT re-required at continuation.
Not covered when
- Cirrhotic (F4) MASH is excluded
- Alcohol consumption >= 20 g/day (female) or >= 30 g/day (male) is excluded
- Concomitant use with other GLP-1 agonists or GLP-1/GIP agonists is not covered
Policy note: Applies to both Wegovy injection (including Wegovy HD injection) and Wegovy tablet. Specialist prescribing or consultation required (endocrinologist, gastroenterologist, or hepatologist). Documentation is required as noted throughout criteria. ELF score range of 9.2 to 10.5 is specifically required (not just >= 9.2). For continuation, fibrosis documentation is NOT re-required; prescriber attestation of no worsening is sufficient. Rezdiffra (resmetirom) is referenced as an alternative MASH treatment in the fibrosis staging lookback criteria.
Policy effective April 15, 2026 · verified June 2, 2026 · source: cnf_684_coveragepositioncriteria_weight_loss_glp1_agonists_pa.pdf