Applies to Employer plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
MASH with moderate to advanced fibrosis (F2-F3)
All of:
- Diagnosis of noncirrhotic MASH (formerly NASH) with moderate to advanced liver fibrosis consistent with stages F2 to F3 (medical records required)
- Stage F2 or F3 fibrosis confirmed by one of: liver biopsy, VCTE, ELF score, or MRE (prior to therapy)
- Requested agent is Wegovy injection
- Patient is an adult (18 years of age or over)
- Patient is being monitored and/or treated for any comorbid conditions (e.g., CVD, diabetes, dyslipidemia, hypertension)
- Patient does NOT have decompensated cirrhosis
- Patient does NOT have moderate to severe hepatic impairment (Child-Pugh Class B or C)
- Patient does NOT have any other liver disease (e.g., Wilson's disease, hepatocellular carcinoma, hepatitis)
- Prescriber is a specialist in the area of the patient's diagnosis (e.g., hepatologist, gastroenterologist) OR has consulted with such a specialist
Plus any one of:
- If patient's sex is female: alcohol consumption < 20 grams/day
- If patient's sex is male: alcohol consumption < 30 grams/day
Documentation to bring
- Medical records confirming diagnosis of noncirrhotic MASH with moderate to advanced liver fibrosis (F2 to F3)
- Fibrosis staging confirmation via one of: liver biopsy report, VCTE result, ELF score result, or MRE result (prior to therapy initiation)
- Documentation of alcohol consumption (< 20g/day for females, < 30g/day for males)
- Documentation of monitoring and/or treatment of comorbid conditions (CVD, diabetes, dyslipidemia, hypertension)
- Documentation confirming absence of: decompensated cirrhosis, Child-Pugh Class B or C hepatic impairment, other liver disease (Wilson's disease, HCC, hepatitis)
- Confirmation that prescriber is a specialist (hepatologist, gastroenterologist) or has consulted with one
Quantity limits
- 0.25 MG/0.5ML, 0.5 MG/0.5ML, 1 MG/0.5ML — 8 pens per 180-day supply (84-day)
- 1.7 MG/0.75ML, 2.4 MG/0.75ML — 4 pens per 28-day supply
- 7.2 MG/0.75ML — 4 pens per 28-day supply
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- Renewal: At renewal, patient must have had clinical benefit with Wegovy. Alcohol consumption limits (<20g/day female, <30g/day male) re-verified. Hepatic exclusions (decompensated cirrhosis, Child-Pugh B/C, other liver disease) re-verified. Specialist requirement re-verified. Stage F2/F3 fibrosis confirmation via biopsy/imaging is NOT re-required at renewal.
Not covered when
- Decompensated cirrhosis
- Moderate to severe hepatic impairment (Child-Pugh Class B or C)
- Any other liver disease (e.g., Wilson's disease, hepatocellular carcinoma, hepatitis)
- Cirrhotic MASH (noncirrhotic required)
- Any FDA labeled contraindications to the requested agent
Exceptions
- BCBS_NM_Fully_Insured_or_HIM: May be approved if patient does not have FDA labeled contraindications AND the requested indication is a rare disease AND patient has another FDA labeled indication or compendia-supported indication.
- Ohio_Fully_Insured_or_HIM_SHOP: May be approved if member resides in Ohio, plan is Fully Insured or HIM Shop (SG), no FDA labeled contraindications, AND patient has another FDA labeled or compendia-supported indication OR prescriber submits two articles from major peer-reviewed journals.
Policy note: Applicable only to Wegovy injection formulation (not Wegovy tablets). Fibrosis must be confirmed prior to therapy initiation. No explicit lookback period stated for biopsy or imaging. Alcohol limits: <20g/day female, <30g/day male (note: one standard drink ~14g). Document notes one standard drink = 12oz regular beer, 5oz wine, or 1.5oz distilled spirits.
Policy effective May 18, 2026 · verified June 2, 2026 · source: Hcsc Weight Management Prog Sum · View policy document (PDF)