Employer / Commercial Insurance
Covered with requirementsWhat you need to qualify
- Age 18 and older
- 6 months of a documented diet and exercise program
- Confirmed MASH diagnosis by FibroScan_VCTE, MRE, and liver_biopsy, fibrosis stage F2 to F3
Qualification pathways
You can qualify through any one of these.
MASH diagnosis verification via imaging alone
All of:
- Age >= 18 years
- Diagnosis of noncirrhotic, nonalcoholic MASH
- Steatosis confirmed by FibroScan VCTE or MRE within the past year
- Moderate to advanced liver fibrosis consistent with stages F2 or F3
- Prior trial and inadequate response to healthcare provider supervised comprehensive lifestyle program
- Will continue to be maintained on healthcare provider supervised comprehensive lifestyle program
MASH diagnosis verification via liver biopsy with NAS score
All of:
- Age >= 18 years
- Diagnosis of noncirrhotic, nonalcoholic MASH
- Liver biopsy within the past 3 years
- NAS score >= 4
- Score of at least 1 in two or more NAS components (steatosis, hepatocellular ballooning, lobular inflammation)
- Moderate to advanced liver fibrosis consistent with stages F2 or F3
- Prior trial and inadequate response to healthcare provider supervised comprehensive lifestyle program
- Will continue to be maintained on healthcare provider supervised comprehensive lifestyle program
Documentation to bring
- Documentation of age >= 18 years
- Diagnosis of noncirrhotic MASH (formerly NASH)
- Imaging or biopsy confirming diagnosis: FibroScan VCTE or MRE within the past year, OR liver biopsy within the past 3 years with NAS score >= 4 and score of at least 1 in two or more NAS components
- Documentation of moderate to advanced liver fibrosis (F2 or F3)
- Documentation of prior trial and inadequate response to healthcare provider supervised comprehensive lifestyle program (worsening or no improvement in NAS score, NAS components, or fibrosis stage)
- Documentation that individual will continue to be maintained on healthcare provider supervised comprehensive lifestyle program
Quantity limits
- 0.25mg, 0.5mg, 1mg, 1.7mg, 2.4mg — Subject to quantity limit (specific limit not detailed in document)
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- To renew, the plan looks for Improvement from baseline in NAFLD Activity Score (NAS) without worsening of fibrosis stage; OR improvement from baseline in fibrosis stage with no worsening of NAS; OR improvement in fibrosis stage based on FibroScan VCTE or MRE. Continued enrollment in healthcare provider supervised comprehensive lifestyle program required.
Not covered when
- BMI < 18.5 kg/m2
- Cirrhosis (stage 4 fibrosis)
- Evidence of other forms of chronic liver disease
- Personal or family history of Medullary Thyroid Carcinoma (MTC)
- Diagnosis of Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
- History of pancreatitis
- Severe gastroparesis
- History of suicide attempts or active suicidal ideation
- Concurrent use of other semaglutide-containing products or any other GLP-1 receptor agonist (including Ozempic, Rybelsus, Zepbound, Mounjaro, Saxenda, Victoza)
- Type 1 diabetes
Policy note: Diagnosis must be noncirrhotic MASH. Imaging confirmation (FibroScan VCTE or MRE) lookback is 12 months; liver biopsy lookback is 36 months. Continuation requires improvement in NAS or fibrosis stage. Pregnancy exclusion not explicitly listed in document but is a standard GLP-1 exclusion; document does not state it explicitly so set to false.
Policy effective April 3, 2026 · verified June 2, 2026 · source: Download