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Excellus BCBS · Liver Disease (MASH)

Excellus BCBS coverage for Wegovy (Liver Disease (MASH))

Employer / Commercial Insurance

Covered with requirements

What you need to qualify

  • Age 18 and older
  • BMI of 35 or higher
  • BMI of 25 or higher for patients of Asian descent
  • 3 months of a documented diet and exercise program
  • Confirmed MASH diagnosis, fibrosis stage F2 to F3

Qualification 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
  • To renew, the plan looks for at least 5% weight loss from the starting weight, 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, at least 17 weeks on therapy before the first renewal, and staying on a maintenance dose of at least 1.7 mg. Make sure your starting weight and date are in the chart now — renewal is measured against it.

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

ACA Marketplace

Covered with requirements

What you need to qualify

  • Age 18 and older
  • BMI of 35 or higher
  • BMI of 25 or higher for patients of Asian descent
  • 3 months of a documented diet and exercise program
  • Confirmed MASH diagnosis, fibrosis stage F2 to F3

Qualification 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
  • To renew, the plan looks for at least 5% weight loss from the starting weight, 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, at least 17 weeks on therapy before the first renewal, and staying on a maintenance dose of at least 1.7 mg. Make sure your starting weight and date are in the chart now — renewal is measured against it.

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

All Wegovy policies under Excellus BCBS · Check your card