Highmark · Liver Disease (MASH)

Highmark coverage for Wegovy (Liver Disease (MASH))

Employer / Commercial Insurance

Covered with requirements

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.

Initial Authorization — MASH with Wegovy

All of:

Member is 18 years of age or older
Requested medication prescribed by a gastroenterologist or hepatologist, OR by an endocrinologist/metabolic specialist in consultation with a gastroenterologist or hepatologist
Diagnosis of MASH (ICD-10: K75.81) documented by one of: (1) liver biopsy within previous 3 years, (2) NIT with imaging (e.g., transient elastography, VCTE/FibroScan, or MRE) within past 6 months, or (3) ELF blood test within past 6 months
Documentation of stage F2 or F3 fibrosis at baseline confirmed by liver biopsy or NIT
At least one cardiometabolic risk factor documented (see any_of)
Prescriber documents member is utilizing lifestyle interventions (weight loss if indicated, dietary changes, exercise)
Prescriber documents member is currently receiving standard of care pharmacologic treatment to manage comorbid diseases (e.g., CVD, dyslipidemia, diabetes, hypertension)
Prescriber documents no evidence of cirrhosis, hepatic decompensation, or hepatocellular carcinoma (HCC)
Prescriber documents alcohol consumption ≤20 g/day (females) or ≤30 g/day (males)
Member will NOT use Wegovy in combination with a GLP-1 RA or GLP-1 RA combination product (e.g., GLP-1 RA with insulin or GIP RA)

Plus any one of:

BMI ≥25 kg/m² (or ethnicity-adjusted equivalent, e.g., ≥23 kg/m² for Asian ethnicity) OR waist circumference ≥94 cm (males) or ≥80 cm (females) or ethnicity-adjusted equivalent
Fasting serum glucose ≥100 mg/dL, OR 2-hour post-prandial serum glucose ≥140 mg/dL, OR HbA1c ≥5.7%, OR diagnosis of T2DM, OR receiving treatment for T2DM
Plasma triglycerides ≥150 mg/dL OR receiving lipid lowering treatment
Plasma HDL ≤40 mg/dL (males) or ≤50 mg/dL (females) OR receiving lipid lowering treatment
Blood pressure ≥130/85 mmHg OR receiving treatment for hypertension

Reauthorization — MASH with Wegovy

All of:

Requested medication prescribed by a gastroenterologist or hepatologist, OR by an endocrinologist/metabolic specialist in consultation with a gastroenterologist or hepatologist
Member has experienced improvement or stabilization of fibrosis as documented by NIT
Member has NOT progressed to stage F4 fibrosis as documented by NIT
Prescriber documents member continues to utilize lifestyle interventions (weight loss if indicated, dietary changes, exercise)
Prescriber documents member continues to use standard of care pharmacologic treatment to manage comorbid diseases (e.g., CVD, dyslipidemia, diabetes, hypertension)
Prescriber documents no evidence of cirrhosis, hepatic decompensation, or hepatocellular carcinoma (HCC)
Prescriber documents alcohol consumption ≤20 g/day (females) or ≤30 g/day (males)
Member will NOT use Wegovy in combination with a GLP-1 RA or GLP-1 RA combination product
Requested dose is 1.7 mg or 2.4 mg once weekly, OR prescriber attests member is titrating to 1.7 mg or 2.4 mg once weekly

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

ACA Marketplace

Covered with requirements

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.

Initial Authorization – All criteria A through J must be met

All of:

Member is 18 years of age or older
Requested medication prescribed by a gastroenterologist or hepatologist, OR by an endocrinologist/metabolic specialist in consultation with a gastroenterologist or hepatologist
Diagnosis of MASH (ICD-10: K75.81) confirmed by one of: liver biopsy within 3 years, NIT with imaging (e.g., VCTE/FibroScan, MRE) within 6 months, or ELF blood test within 6 months
Documentation of stage F2 or F3 fibrosis at baseline confirmed by liver biopsy or NIT
At least one cardiometabolic risk factor documented (BMI ≥25 kg/m² or ethnicity-adjusted equivalent OR qualifying glucose/diabetes criterion OR qualifying triglyceride/lipid treatment criterion OR qualifying HDL criterion OR qualifying blood pressure/hypertension criterion)
Prescriber documents member is utilizing lifestyle interventions (weight loss if indicated, dietary changes, exercise)
Prescriber documents member is currently receiving standard of care pharmacologic treatment for comorbid diseases (CVD, dyslipidemia, diabetes, hypertension)
Prescriber documents member does not have evidence of cirrhosis, hepatic decompensation, or hepatocellular carcinoma (HCC)
Prescriber documents member's alcohol consumption is ≤20 g/day (females) or ≤30 g/day (males)
Member will NOT use Wegovy in combination with any GLP-1 RA or GLP-1 RA combination products (e.g., GLP-1/insulin, GIP RA combinations)

Cardiometabolic Risk Factor – BMI or Waist Circumference

Plus any one of:

BMI ≥25 kg/m² (or ≥23 kg/m² for Asian ethnicity) or ethnicity-adjusted equivalent
Waist circumference ≥94 cm (males) or ≥80 cm (females) or ethnicity-adjusted equivalent

Cardiometabolic Risk Factor – Glucose/Diabetes

Plus any one of:

Fasting serum glucose ≥100 mg/dL
2-hour post-prandial serum glucose ≥140 mg/dL
HbA1c ≥5.7%
Diagnosis of type 2 diabetes
Member is receiving treatment for type 2 diabetes

Cardiometabolic Risk Factor – Triglycerides/Lipid Treatment

Plus any one of:

Plasma triglycerides ≥150 mg/dL
Member is receiving lipid lowering treatment

Cardiometabolic Risk Factor – HDL

Plus any one of:

Plasma HDL ≤40 mg/dL for males
Plasma HDL ≤50 mg/dL for females
Member is receiving lipid lowering treatment

Cardiometabolic Risk Factor – Blood Pressure/Hypertension

Plus any one of:

Blood pressure ≥130/85 mmHg
Member is receiving treatment for hypertension

Reauthorization – All criteria A through H must be met

All of:

Requested medication prescribed by a gastroenterologist or hepatologist, OR by an endocrinologist/metabolic specialist in consultation with a gastroenterologist or hepatologist
Member has experienced improvement or stabilization of fibrosis documented by NIT
Member has not progressed to stage F4 fibrosis documented by NIT
Prescriber documents member is utilizing lifestyle interventions (weight loss if indicated, dietary changes, exercise)
Prescriber documents member continues to use standard of care pharmacologic treatment for comorbid diseases (CVD, dyslipidemia, diabetes, hypertension)
Prescriber documents member does not have evidence of cirrhosis, hepatic decompensation, or HCC
Prescriber documents member's alcohol consumption is ≤20 g/day (females) or ≤30 g/day (males)
Member will NOT use Wegovy in combination with any GLP-1 RA or GLP-1 RA combination products
Requested dose is 1.7 mg or 2.4 mg once weekly, OR prescriber attests member is titrating to 1.7 mg or 2.4 mg once weekly

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

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