Does Highmark cover Wegovy?

Requires Anti-Obesity benefit. Available to Commercial Fully Insured, Healthcare Reform (with Anti-Obesity benefit), and Commercial ASO groups electing Anti-Obesity Enhanced Weight Loss Mgmt Policy. Delaware Commercial fully-insured and Healthcare Reform plans without anti-obesity benefit may access Wegovy only via the CV risk reduction criteria in Section V.

What you need to qualify

• Age 12 and older
• BMI of 35 or higher
• Diagnosis documented with a code (E66.0, E66.3)
• 6 months of a documented diet and exercise program
• Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Baseline height, weight, and BMI within 6 months prior to initiating requested medication and/or a GLP-1 medication
• For adolescents: baseline age documented within 6 months prior to initiating requested medication
• For adults (initiation): evidence that baseline BMI >= 40 kg/m2 within 6 months prior to initiating requested medication and/or a GLP-1 medication
• For adolescents (initiation): evidence that baseline BMI >= 35 OR >= 120% of 95th percentile for age and sex
• For adults: lab documentation (within 6 months) of prediabetes, triglycerides, and HDL if qualifying via metabolic comorbidity pathway
• For adults: clinical documentation of qualifying organ dysfunction comorbidity if qualifying via that pathway
• Table A documentation of dietary changes (e.g., provider chart notes, dietary log, nutritional counseling receipts) for at least 6 months prior to initiation
• Table A documentation of physical activity (e.g., provider chart notes, gym membership receipts, wearable device summary, personal trainer receipts) for at least 6 months prior to initiation
• Prescriber attestation that member does NOT have a diagnosis of type 2 diabetes mellitus (ICD-10: E11.9)
• Prescriber attestation that member will not use Wegovy in combination with any GLP-1 RA or GLP-1 RA combination
• Documentation of therapeutic intolerance (severe side effects not resolved by diet modification or dose de-escalation) or contraindication (allergic reaction, hypersensitivity) to plan-preferred Zepbound (for adults requesting Wegovy over Zepbound)
• For maintenance: current height, weight, and BMI
• For adolescent maintenance: documentation of >= 5% BMI reduction from baseline
• For adult maintenance: documentation of >= 7.5% weight loss from baseline
• For maintenance: prescriber attestation or documentation that requested dose meets maintenance dose requirements

Approval and renewal

• Initial approval: 7 months
• Renewal: every 12 months
• To renew, the plan looks for at least 5% reduction in BMI, For adolescent continuation (Section III): member must have experienced and maintained at least a 5% BMI reduction from baseline. For adult continuation (Section IV): member must have experienced and maintained >= 7.5% weight loss from baseline. T2DM exclusion (no E11.9 diagnosis) is re-verified at continuation. Maintenance dose requirements must be met at continuation (Wegovy injection: 1.7 mg, 2.4 mg, or 7.2 mg for adults 18+; 1.7 mg or 2.4 mg for patients 17 and under; or prescriber attests titrating to maintenance dose. Wegovy oral tablet: 25 mg once daily or titrating to it). Step therapy to Zepbound: for adults 18+, Wegovy (Saxenda, Foundayo) requires documented intolerance or contraindication to plan-preferred Zepbound, and staying on a maintenance dose of at least 1.7 mg.

Not covered when

• Type 2 diabetes mellitus (ICD-10: E11.9) — prescriber must attest member does NOT have T2DM diagnosis
• Concomitant use with any GLP-1 RA or GLP-1 RA combination (e.g., with insulin, GIP RA)
• Wegovy oral tablets not approved for pediatric obesity
• Personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2 (contraindication)
• Previous allergic reaction or hypersensitivity to semaglutide (contraindication)
• Pancreatitis occurring while on therapy — do not switch to another agent
• Pregnancy

Exceptions

• Delaware: Members with a Delaware Commercial fully-insured or Healthcare Reform plan without the anti-obesity benefit may be eligible for Wegovy coverage if criteria in Section V (CV risk reduction) are met. Wegovy for weight loss under anti-obesity benefit criteria (Sections III and IV) still requires the anti-obesity benefit.

Policy note: This policy (J-1388) is the 'Enhanced' anti-obesity policy. The 'Standard' version is J-1389. For Commercial ASO groups, the Anti-Obesity Weight Loss Mgmt Policy must = Enhanced. Zepbound is the plan-preferred agent; Wegovy requires step through Zepbound failure (intolerance or contraindication) for adults 18+. For adolescents initiating (Section III), step through Zepbound is not required. The adult weight loss criteria (Section IV) require BMI >= 40 with a qualifying comorbidity — this is notably higher than FDA label BMI thresholds of 27/30. Adolescent criteria (Section III) require BMI >= 35 OR >= 120% of 95th percentile. Members established on samples or paying out-of-pocket may only continue if policy criteria are met. Wegovy HD (7.2 mg) is available for adults 18+ requiring additional weight loss; it is not a recommended maintenance dose for CV risk reduction or MASH and is not available for members 17 and younger. Wegovy oral tablet is covered under weight loss criteria for adults 18+. Initiation approval = up to 7 months; maintenance approval = up to 12 months. If pancreatitis occurs, member should not switch to another GLP-1 agent.

Policy effective April 24, 2026 · verified June 2, 2026 · source: J-1388-027.pdf

Requires Anti-Obesity benefit. Available to Commercial Fully Insured, Healthcare Reform (with Anti-Obesity benefit), and Commercial ASO groups electing Anti-Obesity Enhanced Weight Loss Mgmt Policy. Delaware Commercial fully-insured and Healthcare Reform plans without anti-obesity benefit may access Wegovy only via the CV risk reduction criteria in Section V.

What you need to qualify

• Age 12 and older
• BMI of 35 or higher
• Diagnosis documented with a code (E66.0, E66.3)
• 6 months of a documented diet and exercise program
• Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Baseline height, weight, and BMI within 6 months prior to initiating requested medication and/or a GLP-1 medication
• For adolescents: baseline age documented within 6 months prior to initiating requested medication
• For adults (initiation): evidence that baseline BMI >= 40 kg/m2 within 6 months prior to initiating requested medication and/or a GLP-1 medication
• For adolescents (initiation): evidence that baseline BMI >= 35 OR >= 120% of 95th percentile for age and sex
• For adults: lab documentation (within 6 months) of prediabetes, triglycerides, and HDL if qualifying via metabolic comorbidity pathway
• For adults: clinical documentation of qualifying organ dysfunction comorbidity if qualifying via that pathway
• Table A documentation of dietary changes (e.g., provider chart notes, dietary log, nutritional counseling receipts) for at least 6 months prior to initiation
• Table A documentation of physical activity (e.g., provider chart notes, gym membership receipts, wearable device summary, personal trainer receipts) for at least 6 months prior to initiation
• Prescriber attestation that member does NOT have a diagnosis of type 2 diabetes mellitus (ICD-10: E11.9)
• Prescriber attestation that member will not use Wegovy in combination with any GLP-1 RA or GLP-1 RA combination
• Documentation of therapeutic intolerance (severe side effects not resolved by diet modification or dose de-escalation) or contraindication (allergic reaction, hypersensitivity) to plan-preferred Zepbound (for adults requesting Wegovy over Zepbound)
• For maintenance: current height, weight, and BMI
• For adolescent maintenance: documentation of >= 5% BMI reduction from baseline
• For adult maintenance: documentation of >= 7.5% weight loss from baseline
• For maintenance: prescriber attestation or documentation that requested dose meets maintenance dose requirements

Approval and renewal

• Initial approval: 7 months
• Renewal: every 12 months
• To renew, the plan looks for at least 5% reduction in BMI, For adolescent continuation (Section III): member must have experienced and maintained at least a 5% BMI reduction from baseline. For adult continuation (Section IV): member must have experienced and maintained >= 7.5% weight loss from baseline. T2DM exclusion (no E11.9 diagnosis) is re-verified at continuation. Maintenance dose requirements must be met at continuation (Wegovy injection: 1.7 mg, 2.4 mg, or 7.2 mg for adults 18+; 1.7 mg or 2.4 mg for patients 17 and under; or prescriber attests titrating to maintenance dose. Wegovy oral tablet: 25 mg once daily or titrating to it). Step therapy to Zepbound: for adults 18+, Wegovy (Saxenda, Foundayo) requires documented intolerance or contraindication to plan-preferred Zepbound, and staying on a maintenance dose of at least 1.7 mg.

Not covered when

• Type 2 diabetes mellitus (ICD-10: E11.9) — prescriber must attest member does NOT have T2DM diagnosis
• Concomitant use with any GLP-1 RA or GLP-1 RA combination (e.g., with insulin, GIP RA)
• Wegovy oral tablets not approved for pediatric obesity
• Personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2 (contraindication)
• Previous allergic reaction or hypersensitivity to semaglutide (contraindication)
• Pancreatitis occurring while on therapy — do not switch to another agent
• Pregnancy

Exceptions

• Delaware: Members with a Delaware Commercial fully-insured or Healthcare Reform plan without the anti-obesity benefit may be eligible for Wegovy coverage if criteria in Section V (CV risk reduction) are met. Wegovy for weight loss under anti-obesity benefit criteria (Sections III and IV) still requires the anti-obesity benefit.

Policy note: This policy (J-1388) is the 'Enhanced' anti-obesity policy. The 'Standard' version is J-1389. For Commercial ASO groups, the Anti-Obesity Weight Loss Mgmt Policy must = Enhanced. Zepbound is the plan-preferred agent; Wegovy requires step through Zepbound failure (intolerance or contraindication) for adults 18+. For adolescents initiating (Section III), step through Zepbound is not required. The adult weight loss criteria (Section IV) require BMI >= 40 with a qualifying comorbidity — this is notably higher than FDA label BMI thresholds of 27/30. Adolescent criteria (Section III) require BMI >= 35 OR >= 120% of 95th percentile. Members established on samples or paying out-of-pocket may only continue if policy criteria are met. Wegovy HD (7.2 mg) is available for adults 18+ requiring additional weight loss; it is not a recommended maintenance dose for CV risk reduction or MASH and is not available for members 17 and younger. Wegovy oral tablet is covered under weight loss criteria for adults 18+. Initiation approval = up to 7 months; maintenance approval = up to 12 months. If pancreatitis occurs, member should not switch to another GLP-1 agent.

Policy effective April 24, 2026 · verified June 2, 2026 · source: J-1388-027.pdf

For members WITH the anti-obesity benefit, this is covered under that benefit. For Delaware Commercial fully-insured or Healthcare Reform members WITHOUT the anti-obesity benefit, coverage is available under Section V criteria. This section explicitly applies to 'members with a DE Commercial fully-insured or Healthcare Reform plan without the anti-obesity benefit only'.

What you need to qualify

• Age 18 and older
• BMI of 27 or higher
• Diagnosis documented with a code (I21, I63, I73.9)
• 6 months of a documented diet and exercise program
• Established cardiovascular disease (MI, stroke, and PAD)
• On guideline-directed medical therapy (statin, ezetimibe, and PCSK9_inhibitor)

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Baseline height, weight, and BMI within 6 months prior to initiating requested medication and/or a GLP-1 medication (must show BMI >= 27 kg/m2)
• Documentation of pre-existing qualifying CVD event: myocardial infarction (ICD-10: I21), stroke (ICD-10: I63), or peripheral arterial disease (ICD-10: I73.9) with supporting documentation of ABI < 0.85 at rest, revascularization procedure, or amputation due to atherosclerotic disease
• Documentation of current use of maximally-tolerated statin therapy AND ezetimibe, OR documentation of statin intolerance (at least two separate statin trials with rhabdomyolysis/muscle symptoms resolving upon discontinuation; OR CK > 10x ULN, LFTs > 3x ULN, or hospitalization due to severe statin-related AE) AND therapeutic failure/contraindication/intolerance to ezetimibe monotherapy
• Documentation of current use of a PCSK9 inhibitor (e.g., Praluent, Repatha) as adjunct, OR documentation of therapeutic failure, contraindication, or intolerance to PCSK9 inhibitor
• Table A documentation of dietary changes (e.g., provider chart notes, dietary log, nutritional counseling receipts) for at least 6 months prior to initiation
• Table A documentation of physical activity (e.g., provider chart notes, gym membership receipts, wearable device summary, personal trainer receipts) for at least 6 months prior to initiation
• If member has T2DM (ICD-10: E11.9): documentation of therapeutic failure to a preferred GLP-1 RA that is FDA-approved for both diabetes and CV risk reduction (e.g., Ozempic)
• Prescriber attestation that member will not use Wegovy in combination with any GLP-1 RA or GLP-1 RA combination
• For maintenance: documentation that requested dose is 1.7 mg or 2.4 mg once weekly (injection) or 25 mg once daily (oral tablet), or prescriber attestation of titrating to maintenance dose

Approval and renewal

• Initial approval: 7 months
• Renewal: every 12 months
• To renew, the plan looks for At maintenance/continuation, the CV qualifying event (MI, stroke, or PAD), BMI >= 27, GDMT requirements (statin/ezetimibe and PCSK9 inhibitor), and T2DM step therapy are all re-verified. No weight loss threshold is required for continuation. Maintenance dose requirements: Wegovy injection 1.7 mg or 2.4 mg once weekly (or titrating to this); Wegovy oral tablet 25 mg once daily (or titrating to this). Note: 7.2 mg (Wegovy HD) is NOT a recommended maintenance dose for CV risk reduction and staying on a maintenance dose of at least 1.7 mg.

Not covered when

• Concomitant use with any GLP-1 RA or GLP-1 RA combination (e.g., with insulin, GIP RA)
• If T2DM diagnosed: must have failed a preferred diabetes GLP-1 RA with CV indication (e.g., Ozempic) before Wegovy is approved for CV risk reduction
• 7.2 mg dose (Wegovy HD) is NOT a recommended maintenance dose for cardiovascular risk reduction
• Personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2 (contraindication)
• Previous allergic reaction or hypersensitivity to semaglutide (contraindication)
• Pancreatitis occurring while on therapy — do not switch to another agent
• Pregnancy

Exceptions

• Delaware: Section V (CV risk reduction) applies ONLY to Delaware Commercial fully-insured or Healthcare Reform plan members WITHOUT the anti-obesity benefit. Members with the anti-obesity benefit would access Wegovy for CV risk reduction under standard benefit criteria.

Policy note: This section applies specifically to Delaware members without the anti-obesity benefit. The GDMT requirement is layered: member must meet BOTH the statin/ezetimibe pathway (or statin intolerance exception) AND the PCSK9 inhibitor pathway (use or prior failure). If member has T2DM, they must have failed a GLP-1 RA approved for both diabetes and CV risk reduction (example given: Ozempic) before Wegovy is approved. The CV risk reduction indication does not exclude T2DM patients but requires prior GLP-1 failure in T2DM patients. This is distinct from the weight_loss indication which explicitly excludes T2DM patients. Initiation = up to 7 months; maintenance = up to 12 months.

Policy effective April 24, 2026 · verified June 2, 2026 · source: J-1388-027.pdf

For members WITH the anti-obesity benefit, this is covered under that benefit. For Delaware Commercial fully-insured or Healthcare Reform members WITHOUT the anti-obesity benefit, coverage is available under Section V criteria. This section explicitly applies to 'members with a DE Commercial fully-insured or Healthcare Reform plan without the anti-obesity benefit only'.

What you need to qualify

• Age 18 and older
• BMI of 27 or higher
• Diagnosis documented with a code (I21, I63, I73.9)
• 6 months of a documented diet and exercise program
• Established cardiovascular disease (MI, stroke, and PAD)
• On guideline-directed medical therapy (statin, ezetimibe, and PCSK9_inhibitor)

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Baseline height, weight, and BMI within 6 months prior to initiating requested medication and/or a GLP-1 medication (must show BMI >= 27 kg/m2)
• Documentation of pre-existing qualifying CVD event: myocardial infarction (ICD-10: I21), stroke (ICD-10: I63), or peripheral arterial disease (ICD-10: I73.9) with supporting documentation of ABI < 0.85 at rest, revascularization procedure, or amputation due to atherosclerotic disease
• Documentation of current use of maximally-tolerated statin therapy AND ezetimibe, OR documentation of statin intolerance (at least two separate statin trials with rhabdomyolysis/muscle symptoms resolving upon discontinuation; OR CK > 10x ULN, LFTs > 3x ULN, or hospitalization due to severe statin-related AE) AND therapeutic failure/contraindication/intolerance to ezetimibe monotherapy
• Documentation of current use of a PCSK9 inhibitor (e.g., Praluent, Repatha) as adjunct, OR documentation of therapeutic failure, contraindication, or intolerance to PCSK9 inhibitor
• Table A documentation of dietary changes (e.g., provider chart notes, dietary log, nutritional counseling receipts) for at least 6 months prior to initiation
• Table A documentation of physical activity (e.g., provider chart notes, gym membership receipts, wearable device summary, personal trainer receipts) for at least 6 months prior to initiation
• If member has T2DM (ICD-10: E11.9): documentation of therapeutic failure to a preferred GLP-1 RA that is FDA-approved for both diabetes and CV risk reduction (e.g., Ozempic)
• Prescriber attestation that member will not use Wegovy in combination with any GLP-1 RA or GLP-1 RA combination
• For maintenance: documentation that requested dose is 1.7 mg or 2.4 mg once weekly (injection) or 25 mg once daily (oral tablet), or prescriber attestation of titrating to maintenance dose

Approval and renewal

• Initial approval: 7 months
• Renewal: every 12 months
• To renew, the plan looks for At maintenance/continuation, the CV qualifying event (MI, stroke, or PAD), BMI >= 27, GDMT requirements (statin/ezetimibe and PCSK9 inhibitor), and T2DM step therapy are all re-verified. No weight loss threshold is required for continuation. Maintenance dose requirements: Wegovy injection 1.7 mg or 2.4 mg once weekly (or titrating to this); Wegovy oral tablet 25 mg once daily (or titrating to this). Note: 7.2 mg (Wegovy HD) is NOT a recommended maintenance dose for CV risk reduction and staying on a maintenance dose of at least 1.7 mg.

Not covered when

• Concomitant use with any GLP-1 RA or GLP-1 RA combination (e.g., with insulin, GIP RA)
• If T2DM diagnosed: must have failed a preferred diabetes GLP-1 RA with CV indication (e.g., Ozempic) before Wegovy is approved for CV risk reduction
• 7.2 mg dose (Wegovy HD) is NOT a recommended maintenance dose for cardiovascular risk reduction
• Personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2 (contraindication)
• Previous allergic reaction or hypersensitivity to semaglutide (contraindication)
• Pancreatitis occurring while on therapy — do not switch to another agent
• Pregnancy

Exceptions

• Delaware: Section V (CV risk reduction) applies ONLY to Delaware Commercial fully-insured or Healthcare Reform plan members WITHOUT the anti-obesity benefit. Members with the anti-obesity benefit would access Wegovy for CV risk reduction under standard benefit criteria.

Policy note: This section applies specifically to Delaware members without the anti-obesity benefit. The GDMT requirement is layered: member must meet BOTH the statin/ezetimibe pathway (or statin intolerance exception) AND the PCSK9 inhibitor pathway (use or prior failure). If member has T2DM, they must have failed a GLP-1 RA approved for both diabetes and CV risk reduction (example given: Ozempic) before Wegovy is approved. The CV risk reduction indication does not exclude T2DM patients but requires prior GLP-1 failure in T2DM patients. This is distinct from the weight_loss indication which explicitly excludes T2DM patients. Initiation = up to 7 months; maintenance = up to 12 months.

Policy effective April 24, 2026 · verified June 2, 2026 · source: J-1388-027.pdf

What you need to qualify

• Age 18 and older
• BMI of 25 or higher
• BMI of 23 or higher for patients of Asian descent
• Diagnosis documented with a code (K75.81)
• 6 months of a documented diet and exercise program
• Prescribed by or in consultation with a specialist
• On guideline-directed medical therapy (standard of care pharmacologic treatment for comorbid diseases (e.g., cardiovascular disease, dyslipidemia, diabetes, hypertension))
• Confirmed MASH diagnosis by liver_biopsy, FibroScan_VCTE, MRE, and ELF_test, fibrosis stage F2 to F3

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Diagnosis of MASH (ICD-10: K75.81) confirmed by one of: liver biopsy within previous 3 years; NIT with imaging (VCTE/FibroScan or MRE) within past 6 months; or ELF blood test within past 6 months
• Documentation of stage F2 or F3 fibrosis at baseline (by liver biopsy or NIT)
• Documentation of at least one qualifying cardiometabolic risk factor (BMI/waist circumference, glucose/HbA1c/T2DM, triglycerides/lipid treatment, HDL levels/lipid treatment, blood pressure/hypertension treatment)
• Prescriber attestation that member is utilizing lifestyle interventions (weight loss if indicated, dietary changes, exercise)
• Prescriber documentation that member is currently receiving standard of care pharmacologic treatment for comorbid diseases (CVD, dyslipidemia, diabetes, hypertension)
• Prescriber documentation that member has no evidence of cirrhosis, hepatic decompensation, or hepatocellular carcinoma (HCC)
• Prescriber documentation that member's alcohol consumption is ≤20 g/day (females) or ≤30 g/day (males)
• Confirmation that member will NOT use Wegovy in combination with any GLP-1 RA or GLP-1 RA combination product
• Prescription must be from a gastroenterologist, hepatologist, or an endocrinologist/metabolic specialist in consultation with a gastroenterologist or hepatologist
• [Reauthorization] NIT documentation of improvement or stabilization of fibrosis and confirmation of no progression to F4 fibrosis
• [Reauthorization] Confirmation that requested dose is 1.7 mg or 2.4 mg once weekly, or attestation that member is titrating to that dose

Approval and renewal

• Initial approval: 6 months
• Renewal: every 12 months
• To renew, the plan looks for Improvement or stabilization of fibrosis as documented by NIT; member has not progressed to stage F4 fibrosis. At reauthorization, the age criterion (>=18) and cardiometabolic risk factor criteria (criterion E) are not re-verified. Member must be at or titrating toward maintenance dose of 1.7 mg or 2.4 mg once weekly, at least 17 weeks on therapy before the first renewal, and staying on a maintenance dose of at least 1.7 mg.

Not covered when

• Cirrhosis or evidence of hepatic decompensation
• Hepatocellular carcinoma (HCC)
• Alcohol consumption >20 g/day (females) or >30 g/day (males)
• Concomitant use with GLP-1 RA or GLP-1 RA combination products (e.g., with insulin or GIP RA)
• Moderate to severe hepatic impairment
• Wegovy oral tablets are not covered under this policy (only single-dose pen injector)
• Wegovy HD 7.2 mg dose is not a recommended maintenance dose for MASH and is not covered under this policy
• Disease states outside FDA-approved indications are denied

Exceptions

• note: An exception to some or all criteria may be granted for select members and/or circumstances based on state and/or federal regulations (Section III of Approval Criteria).

Policy note: This policy (J-1379) covers Wegovy single-dose pen injector ONLY for the MASH indication. For other Wegovy indications (weight loss, CV risk reduction), see policies J-0026, J-0184, J-1388, and J-1389. Wegovy oral tablets are NOT covered under this policy for MASH. The 0.25 mg, 0.5 mg, and 1 mg doses are initiation/escalation doses only; 1.7 mg and 2.4 mg are the approved maintenance doses for MASH. Patients may take at least 17 weeks to reach maintenance dose. Initial authorization is up to 6 months; reauthorization is up to 12 months. Healthcare Reform (HCR/Marketplace) is listed as 'Not Applicable' for Wegovy under this policy. FIB-4 alone should not be used to diagnose MASH per November 2025 AASLD guidance. Asian ethnicity BMI threshold of ≥23 kg/m² applies as a cardiometabolic risk factor criterion. Rezdiffra (resmetirom) is also covered under this policy but is not an in-scope GLP-1 medication and therefore no criteria entry is emitted for it.

Policy effective April 3, 2026 · verified July 27, 2026 · source: J-1379-008.pdf

What you need to qualify

• Age 18 and older
• BMI of 25 or higher
• BMI of 23 or higher for patients of Asian descent
• Diagnosis documented with a code (K75.81)
• 6 months of a documented diet and exercise program
• Prescribed by or in consultation with a specialist
• On guideline-directed medical therapy (standard of care pharmacologic treatment for comorbid diseases including cardiovascular disease, dyslipidemia, diabetes, hypertension)
• Confirmed MASH diagnosis by liver_biopsy, FibroScan_VCTE, MRE, and ELF_test, fibrosis stage F2 to F3
• Lab results confirming eligibility from the last 6 months

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Documentation of MASH diagnosis (ICD-10: K75.81) confirmed by one of: liver biopsy within prior 3 years, NIT with imaging (VCTE/FibroScan or MRE) within prior 6 months, or ELF blood test within prior 6 months
• Documentation of stage F2 or F3 fibrosis at baseline (via liver biopsy or NIT)
• Documentation of at least one qualifying cardiometabolic risk factor (BMI, waist circumference, glucose/diabetes, triglycerides/lipid treatment, HDL, or blood pressure/hypertension treatment)
• Prescriber attestation that member is utilizing lifestyle interventions (weight loss if indicated, dietary changes, exercise)
• Prescriber attestation that member is currently receiving standard of care pharmacologic treatment for comorbid diseases (CVD, dyslipidemia, diabetes, hypertension)
• Prescriber attestation that member does not have evidence of cirrhosis, hepatic decompensation, or hepatocellular carcinoma (HCC)
• Prescriber attestation that member's alcohol consumption is ≤20 g/day (females) or ≤30 g/day (males)
• Prescriber attestation that Wegovy will NOT be used in combination with any GLP-1 RA or GLP-1 RA combination product
• Prescription must be from gastroenterologist or hepatologist, or endocrinologist/metabolic specialist in consultation with gastroenterologist or hepatologist
• [Reauthorization only] NIT documentation of improvement or stabilization of fibrosis
• [Reauthorization only] NIT documentation that member has not progressed to stage F4 fibrosis
• [Reauthorization only] Prescriber attestation that requested dose is 1.7 mg or 2.4 mg once weekly, or that member is titrating to that dose

Quantity limits

• 0.25mg, 0.5mg, 1mg, 1.7mg, 2.4mg

Approval and renewal

• Initial approval: 6 months
• Renewal: every 12 months
• To renew, the plan looks for Improvement or stabilization of fibrosis documented by NIT; member has not progressed to stage F4 fibrosis as documented by NIT. At reauthorization, cardiometabolic risk factor criteria (BMI, glucose, lipids, BP) are NOT re-verified. Age criterion is NOT re-verified. Wegovy-specific: member must be at dose 1.7 mg or 2.4 mg once weekly, or prescriber attests member is titrating to that dose, at least 17 weeks on therapy before the first renewal, and staying on a maintenance dose of at least 1.7 mg.

Not covered when

• Cirrhosis or evidence of hepatic decompensation
• Hepatocellular carcinoma (HCC)
• Alcohol consumption exceeding ≤20 g/day (females) or ≤30 g/day (males)
• Concomitant use with any GLP-1 RA or GLP-1 RA combination product (e.g., with insulin, GIP RA)
• Decompensated cirrhosis or moderate to severe hepatic impairment
• Wegovy oral tablets (not approved for MASH under this policy; only single-dose pen injectors 0.25 mg, 0.5 mg, 1 mg, 1.7 mg, 2.4 mg are covered)
• Wegovy HD 7.2 mg dose (not a recommended maintenance dose for MASH)
• F4 fibrosis (cirrhosis) — not covered; policy covers F2-F3 only
• Healthcare Reform (HCR) members: policy states Not Applicable for HCR for Wegovy MASH

Exceptions

• note: An exception to some or all criteria may be granted for select members and/or circumstances based on state and/or federal regulations (per Section III of Approval Criteria).

Policy note: 1. This policy (J-1379) covers Wegovy ONLY for the MASH indication. For other Wegovy indications (weight loss, CV risk reduction), see policies J-0026, J-0184, J-1388, and J-1389. 2. Maintenance dose for MASH is 1.7 mg or 2.4 mg once weekly; 0.25 mg, 0.5 mg, and 1 mg are titration doses only and not approved maintenance doses. Patients may take at least 17 weeks to reach maintenance dose. 3. Wegovy HD 7.2 mg is only for patients requiring additional weight loss and is not a recommended maintenance dose for MASH. 4. Initial authorization duration is up to 6 months; reauthorization is up to 12 months. 5. FIB-4 alone should NOT be used to diagnose MASH per November 2025 AASLD guidance. 6. MASH confirmation via NIT with imaging or ELF blood test must be within 6 months; liver biopsy within 3 years. 7. The cardiometabolic risk factor criteria reference ethnicity-adjusted BMI (≥23 kg/m² for Asian ethnicity) and waist circumference equivalents. 8. Healthcare Reform line of business is listed as 'Not Applicable' for Wegovy under this policy.

Policy effective April 3, 2026 · verified June 2, 2026 · source: J-1379-008.pdf