Applies to Employer plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
MASH with F2/F3 fibrosis (Wegovy)
All of:
- Diagnosis of noncirrhotic NASH or MASH (medical records required)
- Stage F2 or F3 fibrosis confirmed by BOTH: (1) FIB-4 score consistent with F2 or F3 fibrosis adjusted for age AND (2) one confirmatory test (liver biopsy, VCTE/FibroScan, ELF score, or MRE)
- Requested agent is Wegovy
- Patient is an adult (≥ 18 years of age)
- 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, HCC, hepatitis)
- Prescriber is a specialist (hepatologist, gastroenterologist) OR has consulted with such a specialist
- Will NOT use in combination with another weight loss agent
- Will NOT use in combination with another GLP-1 receptor agonist
- No FDA labeled contraindications to requested agent
- Currently on low-calorie diet, increased physical activity, and behavioral modifications
Plus any one of:
- BMI > 25 kg/m2
- BMI > 23 kg/m2 if patient is of South Asian, Southeast Asian, or East Asian descent
- If female: alcohol consumption < 20 grams/day
- If male: alcohol consumption < 30 grams/day
Documentation to bring
- Medical records confirming diagnosis of noncirrhotic NASH or MASH
- FIB-4 score consistent with stage F2 or F3 fibrosis (adjusted for age)
- One of the following confirming F2 or F3 fibrosis: liver biopsy, vibration-controlled transient elastography (VCTE/FibroScan), Enhanced Liver Fibrosis (ELF) score, or magnetic resonance elastography (MRE)
- Documentation of patient BMI (> 25 kg/m2, or > 23 kg/m2 for South/Southeast/East Asian patients)
- Documentation of alcohol consumption (< 20 g/day female, < 30 g/day male)
- Documentation confirming absence of decompensated cirrhosis, Child-Pugh B/C, and other liver diseases
- Documentation of monitoring/treatment for comorbid conditions (CVD, diabetes, dyslipidemia, hypertension)
- Documentation of specialist involvement (hepatologist or gastroenterologist) or consultation
Quantity limits
- 0.25mg, 0.5mg, 1mg — 8 pens per 180 days (84-day)
- 1.7mg, 2.4mg — 4 pens per 28 days
Approval and renewal
- Initial approval: 6 months
- Renewal: every 6 months
- Renewal: Patient must have clinical benefit with the requested agent. Alcohol limits (< 20 g/day female, < 30 g/day male) re-verified at renewal. Absence of decompensated cirrhosis, Child-Pugh B/C, and other liver disease re-verified. Specialist requirement re-verified. Fibrosis staging and BMI are NOT re-verified 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)
- Alcohol consumption ≥ 20 g/day (female) or ≥ 30 g/day (male)
- Concomitant use with another weight loss agent
- Concomitant use with another GLP-1 receptor agonist
- Any FDA labeled contraindications to the requested agent
Policy note: Fibrosis must be confirmed by BOTH a FIB-4 score consistent with F2/F3 AND at least one of: liver biopsy, VCTE, ELF score, or MRE. Asian BMI threshold is > 23 kg/m2 for South Asian, Southeast Asian, or East Asian patients. One standard alcoholic drink contains roughly 14 grams of pure alcohol. Initial approval is 6 months (all non-obesity indications). Renewal is 6 months.
verified June 5, 2026 · source: GLP-1 For Non Diabetic Use · View policy document (PDF)