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 — BMI ≥35 with MAFLD/MASH comorbidity
All of:
- Age ≥ 18 years
- Noncirrhotic MASH with moderate to advanced liver fibrosis (F2–F3 fibrosis)
- BMI ≥ 35 kg/m² with qualifying comorbidity (MAFLD/MASH qualifies)
- Enrolled in qualified comprehensive weight management program for ≥3 consecutive months
- Documentation of trial and failure of Foundayo OR documented contraindication to Foundayo
- Not used in combination with any other GIP and/or GLP-1 receptor agonist
- Not used in combination with other weight loss drugs (Rx, OTC, or herbal)
Documentation to bring
- Baseline BMI documentation (≥35 kg/m²)
- Documentation of noncirrhotic MASH with F2–F3 fibrosis
- Documentation of MAFLD/MASH as qualifying comorbidity
- Documentation of current enrollment in qualified comprehensive weight management program for ≥3 consecutive months
- Proof of participation in comprehensive weight management program (receipt or certificate and dietary/exercise logs)
- Documentation of trial and failure of Foundayo OR documented contraindication to Foundayo
Quantity limits
- 0.25mg, 0.5mg, 1mg, 1.7mg, 2.4mg, 7.2mg (Wegovy HD) — 4 pens per 28 days; Maximum 14 twenty-eight-day supplies OR 5 eighty-four-day supplies per 365 days; first 6 fills for new starts limited to 28-day supply or less (84-day)
- 1.5mg tablet, 4mg tablet, 9mg tablet, 25mg tablet — 30 tablets per 30 days; Maximum 14 thirty-day supplies OR 5 ninety-day supplies per 365 days; first 6 fills for new starts limited to 30-day supply or less (84-day)
Approval and renewal
- Initial approval: 7 months
- Renewal: every 6 months
- Renewal: Continuation criteria follow existing weight management policy: ≥5% weight loss by 7 months, maintained ≥5% weight loss or continued weight loss at subsequent recertifications, BMI not less than 18.5 kg/m², and maintenance dose (1.7mg, 2.4mg, or 7.2mg injection OR 25mg tablet). MASH fibrosis staging not re-verified at continuation per policy structure.
- Renewal: At least 17 weeks on therapy before the first renewal.
- Renewal: Staying on a maintenance dose of at least 1.7 mg.
Not covered when
- BMI < 35 kg/m² considered not medically necessary for MASH even in presence of MAFLD/MASH — insufficient evidence of efficacy in non-obese/overweight population
- Cirrhotic MASH not covered (noncirrhotic only)
- Combination with other GIP and/or GLP-1 receptor agonists not approved
- Combination with other weight loss drugs (Rx, OTC, or herbal) not approved
- MASH indication approved under FDA accelerated approval — continued approval contingent upon verification of clinical benefit in confirmatory trial
Exceptions
- New York: All utilization management requirements compliant with applicable New York State insurance laws and regulations
Policy note: FDA approved Wegovy injection for noncirrhotic MASH with moderate to advanced fibrosis (F2–F3) on August 15, 2025, under accelerated approval. Policy restricts coverage to patients with BMI ≥35 kg/m² by integrating MASH into existing weight management criteria (Class II obesity with MAFLD/MASH comorbidity). Policy explicitly states BMI <35 is not medically necessary citing: <3% of ESSENCE trial participants had BMI <27, mean trial BMI was 34.6, subgroup efficacy in non-obese/overweight not established, primary outcomes were biopsy-confirmed (not hard outcomes), long-term outcomes data expected 2029, and histologic improvements strongly correlate with weight reduction. No specific MASH confirmation method (FIB-4, FibroScan, biopsy, MRE, ELF) is specified in this policy — policy references FDA approval criteria of F2–F3 fibrosis only.
verified June 5, 2026 · source: Weight Management Policy Pdf · View policy document (PDF)