FEP Blue coverage for Wegovy (Liver Disease (MASH))

What you need to qualify

• Age 18 and older
• Prescribed by or in consultation with a specialist
• Confirmed MASH diagnosis by liver_biopsy, FibroScan_VCTE, and MRE, fibrosis stage F2 to F3

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Diagnosis of noncirrhotic MASH (formerly noncirrhotic NASH)
• Documentation of fibrosis stage F2 or F3 confirmed by: liver biopsy within last 6 months (NAS >= 4, OR if NAS < 4, hepatocyte ballooning and steatosis present) OR elastography (e.g., FibroScan), CT, or MRI within last 3 months
• Documentation of monitoring and/or treatment for comorbid conditions (e.g., CVD, diabetes, dyslipidemia, hypertension)
• Prescription from or consultation with an endocrinologist, gastroenterologist, or hepatologist
• Attestation of no stage F4 fibrosis (cirrhosis)
• Attestation of no significant alcohol consumption (< 2 alcoholic drinks/day for > 3 months in the last year)
• Attestation of no hepatocellular carcinoma (HCC) diagnosis
• Attestation of no chronic liver diseases (e.g., primary biliary cholangitis, primary sclerosing cholangitis, Hepatitis B positive, active Hepatitis C)

Quantity limits

• 0.25mg, 0.5mg, 1mg, 1.7mg, 2.4mg — 12 single-dose pens per 84 days (84-day)

Approval and renewal

• Initial approval: 12 months
• Renewal: every 12 months
• To renew, the plan looks for Improvement in fibrosis by at least 1 stage within 1 year of treatment OR no worsening of fibrosis after 2 years or more of therapy. Patient has not progressed to stage F4 (cirrhosis). Metabolic risks are managed to standard of care. Used in conjunction with diet and exercise.

Not covered when

• Stage F4 liver fibrosis (cirrhosis)
• Significant alcohol consumption (>= 2 alcoholic drinks per day for > 3 months in the last year)
• Diagnosis of hepatocellular carcinoma (HCC)
• Chronic liver diseases (e.g., primary biliary cholangitis, primary sclerosing cholangitis, Hepatitis B positive, active Hepatitis C)
• Pediatric patients under 18 years of age (safety and effectiveness not established for MASH in patients < 18)

Policy note: MASH indication applies to Wegovy injection only (not tablets). Wegovy injection only approved for MASH. Liver biopsy confirmation requires NAS >= 4 OR if NAS < 4, hepatocyte ballooning and steatosis must be present. Imaging confirmation (elastography, CT, or MRI) must be within last 3 months. Biopsy must be within last 6 months. Continuation requires fibrosis improvement of at least 1 stage within 1 year OR no worsening after 2+ years. Alcohol limit is stated as 'fewer than 2 alcoholic drinks per day' (i.e., < 2 drinks/day); exact grams not specified in document.

Policy effective July 1, 2026 · verified July 27, 2026 · source: FEP_Criteria_Wegovy.pdf