Applies to Federal Employee Program plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
Wegovy injection — MASH initial approval
All of:
- Age 18 years or older
- Diagnosis of noncirrhotic MASH (formerly noncirrhotic NASH)
- Moderate to advanced liver fibrosis (stages F2 to F3) confirmed by liver biopsy within last 6 months OR elastography/CT/MRI within last 3 months
- Patient is being monitored and/or treated for any comorbid conditions (e.g., CVD, diabetes, dyslipidemia, hypertension)
- Prescribed by, or in consultation with, an endocrinologist, gastroenterologist, or hepatologist
- Used in conjunction with diet and exercise
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
- Renewal: 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 · View policy document (PDF)