Does Kaiser Permanente Mid-Atlantic cover Wegovy?

What you need to qualify

• Age 12 and older
• BMI of 27 or higher
• BMI of 27 or higher with a weight-related condition (CVD, stroke, HTN, T2DM, CKD, CHD, PCOS, dyslipidemia, MASH, MASLD, idiopathic intracranial hypertension, and osteoarthritis in weight-bearing joints)
• 3 months of a documented diet and exercise program
• Prior trial of phentermine, diethylpropion, phentermine/topiramate (generic), Qsymia, naltrexone/bupropion (generic), and Contrave for at least 3 months

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Referral through Pharmacy Review – Injectable Weight Loss OR documentation that prescriber is an Endocrinologist, Pediatrician, or Weight Management Specialist
• Patient age documentation (>=12 years)
• Documented baseline weight within past 30 days
• Documented baseline BMI
• For BMI 27 to <30: documentation of at least one qualifying weight-related comorbidity
• For BMI 27 to <35: documentation of intolerance, contraindication, or failure to lose/maintain >=5% body weight after 3-month trial of qualifying oral weight management medication
• Prescriber-documented lifestyle interventions with nutrition and physical activity components (90 days)
• Documentation that Wegovy is not being used in combination with another GLP-1 RA or GIP/GLP-1 RA
• If ordering oral tablets: documented history of trypanophobia (fear of needles)

Approval and renewal

• Initial approval: 6 months
• Renewal: every 6 months
• To renew, the plan looks for at least 5% weight loss from the starting weight and Documented weight loss of at least 5% from baseline weight within the previous 6 months. Must continue prescriber-documented lifestyle interventions. If BMI is 25 to <27: 3-month x 1 reauthorization only (for deprescribing). If BMI >=27: 6-month reauthorization. Baseline BMI and prior oral weight loss drug step therapy are NOT re-verified at continuation for existing members. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

• Combination use with another GIP/GLP-1 RA or GLP-1 RA not permitted

Policy note: Oral Wegovy tablets require documented history of trypanophobia (fear of needles). Prior oral weight management drug step therapy is NOT required for BMI 35 to <40 or BMI >=40 tiers. Step therapy drugs are preferred as generics over brands (e.g., generic phentermine+topiramate preferred over brand Qsymia). Age restrictions on oral weight management step therapy drugs noted: bupropion/naltrexone combination age >=18; Contrave not indicated <18; diethylpropion age >16; phentermine age >=16; Qsymia age >=12 (max 7.5-46mg daily). Continuation: BMI 25 to <27 allows only one 3-month reauthorization for deprescribing purposes.

Policy effective June 2, 2026 · verified June 5, 2026 · source: hmo-exchange-prior-authorization-criteria-en.pdf

What you need to qualify

• Age 12 and older
• BMI of 27 or higher
• BMI of 27 or higher with a weight-related condition (CVD, stroke, HTN, T2DM, CKD, CHD, PCOS, dyslipidemia, MASH, MASLD, idiopathic intracranial hypertension, and osteoarthritis in weight-bearing joints)
• 3 months of a documented diet and exercise program
• Prior trial of phentermine, diethylpropion, phentermine/topiramate (generic), Qsymia, naltrexone/bupropion (generic), and Contrave for at least 3 months

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Referral through Pharmacy Review – Injectable Weight Loss OR documentation that prescriber is an Endocrinologist, Pediatrician, or Weight Management Specialist
• Patient age documentation (>=12 years)
• Documented baseline weight within past 30 days
• Documented baseline BMI
• For BMI 27 to <30: documentation of at least one qualifying weight-related comorbidity
• For BMI 27 to <35: documentation of intolerance, contraindication, or failure to lose/maintain >=5% body weight after 3-month trial of qualifying oral weight management medication
• Prescriber-documented lifestyle interventions with nutrition and physical activity components (90 days)
• Documentation that Wegovy is not being used in combination with another GLP-1 RA or GIP/GLP-1 RA
• If ordering oral tablets: documented history of trypanophobia (fear of needles)

Approval and renewal

• Initial approval: 6 months
• Renewal: every 6 months
• To renew, the plan looks for at least 5% weight loss from the starting weight and Documented weight loss of at least 5% from baseline weight within the previous 6 months. Must continue prescriber-documented lifestyle interventions. If BMI is 25 to <27: 3-month x 1 reauthorization only (for deprescribing). If BMI >=27: 6-month reauthorization. Baseline BMI and prior oral weight loss drug step therapy are NOT re-verified at continuation for existing members. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

• Combination use with another GIP/GLP-1 RA or GLP-1 RA not permitted

Policy note: Oral Wegovy tablets require documented history of trypanophobia (fear of needles). Prior oral weight management drug step therapy is NOT required for BMI 35 to <40 or BMI >=40 tiers. Step therapy drugs are preferred as generics over brands (e.g., generic phentermine+topiramate preferred over brand Qsymia). Age restrictions on oral weight management step therapy drugs noted: bupropion/naltrexone combination age >=18; Contrave not indicated <18; diethylpropion age >16; phentermine age >=16; Qsymia age >=12 (max 7.5-46mg daily). Continuation: BMI 25 to <27 allows only one 3-month reauthorization for deprescribing purposes.

Policy effective June 2, 2026 · verified June 5, 2026 · source: hmo-exchange-prior-authorization-criteria-en.pdf

What you need to qualify

• Age 12 and older
• BMI of 27 or higher
• BMI of 27 or higher with a weight-related condition (CVD, stroke, HTN, T2DM, CKD, CHD, PCOS, dyslipidemia, MASH, MASLD, idiopathic intracranial hypertension, and osteoarthritis in weight-bearing joints)
• 3 months of a documented diet and exercise program
• Prior trial of phentermine, diethylpropion, phentermine/topiramate (generic), Qsymia, naltrexone/bupropion (generic), and Contrave for at least 3 months

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Referral through Pharmacy Review – Injectable Weight Loss OR documentation that prescriber is an Endocrinologist, Pediatrician, or Weight Management Specialist
• Patient age documentation (>=12 years)
• Documented baseline weight within past 30 days
• Documented baseline BMI
• For BMI 27 to <30: documentation of at least one qualifying weight-related comorbidity
• For BMI 27 to <35: documentation of intolerance, contraindication, or failure to lose/maintain >=5% body weight after 3-month trial of qualifying oral weight management medication
• Prescriber-documented lifestyle interventions with nutrition and physical activity components (90 days)
• Documentation that Wegovy is not being used in combination with another GLP-1 RA or GIP/GLP-1 RA
• If ordering oral tablets: documented history of trypanophobia (fear of needles)

Approval and renewal

• Initial approval: 6 months
• Renewal: every 6 months
• To renew, the plan looks for at least 5% weight loss from the starting weight and Documented weight loss of at least 5% from baseline weight within the previous 6 months. Must continue prescriber-documented lifestyle interventions. If BMI is 25 to <27: 3-month x 1 reauthorization only (for deprescribing). If BMI >=27: 6-month reauthorization. Baseline BMI and prior oral weight loss drug step therapy are NOT re-verified at continuation for existing members. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

• Combination use with another GIP/GLP-1 RA or GLP-1 RA not permitted

Policy note: Oral Wegovy tablets require documented history of trypanophobia (fear of needles). Prior oral weight management drug step therapy is NOT required for BMI 35 to <40 or BMI >=40 tiers. Step therapy drugs are preferred as generics over brands (e.g., generic phentermine+topiramate preferred over brand Qsymia). Age restrictions on oral weight management step therapy drugs noted: bupropion/naltrexone combination age >=18; Contrave not indicated <18; diethylpropion age >16; phentermine age >=16; Qsymia age >=12 (max 7.5-46mg daily). Continuation: BMI 25 to <27 allows only one 3-month reauthorization for deprescribing purposes.

Policy effective June 2, 2026 · verified June 5, 2026 · source: hmo-exchange-prior-authorization-criteria-en.pdf

What you need to qualify

• Age 55 to 74
• BMI of 27 or higher
• A1C no higher than 6.4%
• 3 months of a documented diet and exercise program
• Established cardiovascular disease (MI)
• On guideline-directed medical therapy (moderate- to high-intensity statin or alternative lipid-lowering medication, antiplatelet medication, and antihypertensive medication (beta-blocker, ACEi, ARB, or other))
• Lab results confirming eligibility
• Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Patient age documentation (55 to <75 years)
• Documented baseline weight within past 30 days
• BMI >=27 kg/m2 documentation
• HbA1c lab result confirming <6.5% (no history of diabetes)
• Documentation of established history of MI
• Prescriber-documented lifestyle interventions with nutrition and physical activity components (90 days)
• Documentation of current use of moderate- to high-intensity statin or alternative lipid-lowering medication, OR documented intolerance/contraindication/rationale for not using
• Documentation of current antiplatelet medication use, OR documented intolerance/contraindication/rationale
• Documentation of current antihypertensive medication use, OR documented intolerance/contraindication/rationale
• Confirmation patient is not currently prescribed another GLP-1 RA or GIP/GLP-1 RA
• Confirmation of absence of all reasons for non-coverage (NYHA Class IV HF, recent CV event within 60 days, planned revascularization, T1/T2DM, pancreatitis, MEN2/MTC history, pregnancy status, ESRD/dialysis, malignancy within 5 years, severe psychiatric disorder)
• If ordering oral tablets: documented history of trypanophobia (fear of needles)

Quantity limits

• all strengths — Maximum 30-day supply at initial prescription (with 2 refills); standard fill thereafter

Approval and renewal

• Initial approval: 6 months
• Renewal: every 6 months
• To renew, the plan looks for Must continue actively adhering to prescriber-documented lifestyle interventions (90 days with nutrition and physical activity components). BMI must remain >=27 kg/m2 (discontinue if BMI <27 kg/m2 as medication is no longer clinically indicated). Age, MI history, GDMT optimization, HbA1c exclusion, and other initial exclusions are NOT explicitly re-verified for existing members who have previously met criteria.

Not covered when

• Type 2 diabetes or HbA1c >=6.5%
• NYHA Class IV heart failure
• Recent MI, stroke, hospitalization for unstable angina or TIA within 60 days prior to initiation
• Planned coronary, carotid, or peripheral artery revascularization
• History or presence of chronic or acute pancreatitis
• Personal or first-degree relative history of MEN2 or MTC
• Breastfeeding
• Childbearing potential without highly effective contraception
• ESRD, chronic or intermittent hemodialysis, or peritoneal dialysis
• Malignant neoplasm within past 5 years (excluding basal/squamous cell skin cancer and carcinoma in-situ)
• Severe psychiatric disorder compromising medication adherence
• Currently prescribed another GLP-1 RA or GIP/GLP-1 RA
• Pregnancy
• Type 1 diabetes

Policy note: Qualifying CV event is limited specifically to established history of MI (not broader CVD events like stroke, PAD, or revascularization). Age range is strictly 55 to <75. Diabetes exclusion defined as HbA1c <6.5% — excludes both T1D and T2D. Applies to Wegovy injectable and oral tablets; oral tablets require trypanophobia documentation. Initial prescription limited to 30-day supply with 2 refills. Continuation requires BMI >=27 kg/m2; medication discontinued if BMI falls below 27.

Policy effective June 2, 2026 · verified June 5, 2026 · source: hmo-exchange-prior-authorization-criteria-en.pdf

What you need to qualify

• Age 55 to 74
• BMI of 27 or higher
• A1C no higher than 6.4%
• 3 months of a documented diet and exercise program
• Established cardiovascular disease (MI)
• On guideline-directed medical therapy (moderate- to high-intensity statin or alternative lipid-lowering medication, antiplatelet medication, and antihypertensive medication (beta-blocker, ACEi, ARB, or other))
• Lab results confirming eligibility
• Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Patient age documentation (55 to <75 years)
• Documented baseline weight within past 30 days
• BMI >=27 kg/m2 documentation
• HbA1c lab result confirming <6.5% (no history of diabetes)
• Documentation of established history of MI
• Prescriber-documented lifestyle interventions with nutrition and physical activity components (90 days)
• Documentation of current use of moderate- to high-intensity statin or alternative lipid-lowering medication, OR documented intolerance/contraindication/rationale for not using
• Documentation of current antiplatelet medication use, OR documented intolerance/contraindication/rationale
• Documentation of current antihypertensive medication use, OR documented intolerance/contraindication/rationale
• Confirmation patient is not currently prescribed another GLP-1 RA or GIP/GLP-1 RA
• Confirmation of absence of all reasons for non-coverage (NYHA Class IV HF, recent CV event within 60 days, planned revascularization, T1/T2DM, pancreatitis, MEN2/MTC history, pregnancy status, ESRD/dialysis, malignancy within 5 years, severe psychiatric disorder)
• If ordering oral tablets: documented history of trypanophobia (fear of needles)

Quantity limits

• all strengths — Maximum 30-day supply at initial prescription (with 2 refills); standard fill thereafter

Approval and renewal

• Initial approval: 6 months
• Renewal: every 6 months
• To renew, the plan looks for Must continue actively adhering to prescriber-documented lifestyle interventions (90 days with nutrition and physical activity components). BMI must remain >=27 kg/m2 (discontinue if BMI <27 kg/m2 as medication is no longer clinically indicated). Age, MI history, GDMT optimization, HbA1c exclusion, and other initial exclusions are NOT explicitly re-verified for existing members who have previously met criteria.

Not covered when

• Type 2 diabetes or HbA1c >=6.5%
• NYHA Class IV heart failure
• Recent MI, stroke, hospitalization for unstable angina or TIA within 60 days prior to initiation
• Planned coronary, carotid, or peripheral artery revascularization
• History or presence of chronic or acute pancreatitis
• Personal or first-degree relative history of MEN2 or MTC
• Breastfeeding
• Childbearing potential without highly effective contraception
• ESRD, chronic or intermittent hemodialysis, or peritoneal dialysis
• Malignant neoplasm within past 5 years (excluding basal/squamous cell skin cancer and carcinoma in-situ)
• Severe psychiatric disorder compromising medication adherence
• Currently prescribed another GLP-1 RA or GIP/GLP-1 RA
• Pregnancy
• Type 1 diabetes

Policy note: Qualifying CV event is limited specifically to established history of MI (not broader CVD events like stroke, PAD, or revascularization). Age range is strictly 55 to <75. Diabetes exclusion defined as HbA1c <6.5% — excludes both T1D and T2D. Applies to Wegovy injectable and oral tablets; oral tablets require trypanophobia documentation. Initial prescription limited to 30-day supply with 2 refills. Continuation requires BMI >=27 kg/m2; medication discontinued if BMI falls below 27.

Policy effective June 2, 2026 · verified June 5, 2026 · source: hmo-exchange-prior-authorization-criteria-en.pdf

What you need to qualify

• Age 55 to 74
• BMI of 27 or higher
• A1C no higher than 6.4%
• 3 months of a documented diet and exercise program
• Established cardiovascular disease (MI)
• On guideline-directed medical therapy (moderate- to high-intensity statin or alternative lipid-lowering medication, antiplatelet medication, and antihypertensive medication (beta-blocker, ACEi, ARB, or other))
• Lab results confirming eligibility
• Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Patient age documentation (55 to <75 years)
• Documented baseline weight within past 30 days
• BMI >=27 kg/m2 documentation
• HbA1c lab result confirming <6.5% (no history of diabetes)
• Documentation of established history of MI
• Prescriber-documented lifestyle interventions with nutrition and physical activity components (90 days)
• Documentation of current use of moderate- to high-intensity statin or alternative lipid-lowering medication, OR documented intolerance/contraindication/rationale for not using
• Documentation of current antiplatelet medication use, OR documented intolerance/contraindication/rationale
• Documentation of current antihypertensive medication use, OR documented intolerance/contraindication/rationale
• Confirmation patient is not currently prescribed another GLP-1 RA or GIP/GLP-1 RA
• Confirmation of absence of all reasons for non-coverage (NYHA Class IV HF, recent CV event within 60 days, planned revascularization, T1/T2DM, pancreatitis, MEN2/MTC history, pregnancy status, ESRD/dialysis, malignancy within 5 years, severe psychiatric disorder)
• If ordering oral tablets: documented history of trypanophobia (fear of needles)

Quantity limits

• all strengths — Maximum 30-day supply at initial prescription (with 2 refills); standard fill thereafter

Approval and renewal

• Initial approval: 6 months
• Renewal: every 6 months
• To renew, the plan looks for Must continue actively adhering to prescriber-documented lifestyle interventions (90 days with nutrition and physical activity components). BMI must remain >=27 kg/m2 (discontinue if BMI <27 kg/m2 as medication is no longer clinically indicated). Age, MI history, GDMT optimization, HbA1c exclusion, and other initial exclusions are NOT explicitly re-verified for existing members who have previously met criteria.

Not covered when

• Type 2 diabetes or HbA1c >=6.5%
• NYHA Class IV heart failure
• Recent MI, stroke, hospitalization for unstable angina or TIA within 60 days prior to initiation
• Planned coronary, carotid, or peripheral artery revascularization
• History or presence of chronic or acute pancreatitis
• Personal or first-degree relative history of MEN2 or MTC
• Breastfeeding
• Childbearing potential without highly effective contraception
• ESRD, chronic or intermittent hemodialysis, or peritoneal dialysis
• Malignant neoplasm within past 5 years (excluding basal/squamous cell skin cancer and carcinoma in-situ)
• Severe psychiatric disorder compromising medication adherence
• Currently prescribed another GLP-1 RA or GIP/GLP-1 RA
• Pregnancy
• Type 1 diabetes

Policy note: Qualifying CV event is limited specifically to established history of MI (not broader CVD events like stroke, PAD, or revascularization). Age range is strictly 55 to <75. Diabetes exclusion defined as HbA1c <6.5% — excludes both T1D and T2D. Applies to Wegovy injectable and oral tablets; oral tablets require trypanophobia documentation. Initial prescription limited to 30-day supply with 2 refills. Continuation requires BMI >=27 kg/m2; medication discontinued if BMI falls below 27.

Policy effective June 2, 2026 · verified June 5, 2026 · source: hmo-exchange-prior-authorization-criteria-en.pdf

What you need to qualify

• Age 18 and older
• 3 months of a documented diet and exercise program
• Prescribed by or in consultation with a specialist
• Confirmed MASH diagnosis by FibroScan_VCTE, ultrasound elastography, MRE, and liver_biopsy, fibrosis stage F2 to F3

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Documentation that prescriber is a Hepatologist or Gastroenterologist
• Patient age documentation (>=18 years)
• MASH diagnosis with fibrosis stage F2 or F3 confirmed by transient elastography, ultrasound elastography, MRI elastography, and/or liver biopsy
• Documentation that fibrosis is persistent (F2/F3) and refractory to at least 3 months of lifestyle changes and/or structured weight loss program
• Documentation of absence of significant alcohol consumption within 1 year (females <=7 drinks/week [98g]; males <=14 drinks/week [196g])
• Documentation of absence of regular use of drugs associated with MAFLD
• Documentation of absence of active serious medical disease with life expectancy <2 years
• ALT/AST levels confirming not >5x ULN due to other chronic liver disease
• Confirmation of absence of pregnancy/breastfeeding/planning pregnancy
• Confirmation of no personal or family history of MTC or MEN2
• Confirmation of no prior or current pancreatitis or gallbladder disease/gallstones
• Confirmation of no bariatric surgery within past 6 months

Approval and renewal

• Initial approval: 12 months
• Renewal: every 12 months
• To renew, the plan looks for Clinically significant benefit defined as: NAFLD Activity Score (NAS) decreased by at least 2 points from baseline OR reduction in fibrosis stage. AND specialist follow-up in the last 12 months. Initial criteria (e.g., F2/F3 fibrosis documentation, alcohol consumption exclusion, specialist prescriber requirement) are NOT explicitly re-verified for existing members who have previously met criteria.

Not covered when

• Bariatric surgery within the last 6 months
• Significant alcohol consumption within 1 year (>7 drinks/week [>98g] for females; >14 drinks/week [>196g] for males)
• Regular use of drugs associated with MAFLD (amiodarone, methotrexate, systemic glucocorticoids >5mg/day, tamoxifen, high-dose estrogen, anabolic steroids [except testosterone replacement], valproic acid, known hepatotoxins)
• Active serious medical disease with life expectancy <2 years
• ALT/AST >5x ULN likely due to other chronic liver disease
• Breastfeeding
• Planning to become pregnant
• Personal or family history of MTC or MEN2
• Prior or current pancreatitis or gallbladder disease/gallstones
• Pregnancy
• Bariatric surgery

Policy note: Applies to Wegovy injectable ONLY — oral tablets are NOT covered for MASH indication. Fibrosis confirmation methods include transient elastography (FibroScan), ultrasound elastography, MRI elastography, and/or liver biopsy. No explicit lookback period stated for confirmatory testing. Continuation requires specialist follow-up within last 12 months plus documented clinical benefit (NAS decrease >=2 points or fibrosis stage reduction).

Policy effective June 2, 2026 · verified June 5, 2026 · source: hmo-exchange-prior-authorization-criteria-en.pdf

What you need to qualify

• Age 18 and older
• 3 months of a documented diet and exercise program
• Prescribed by or in consultation with a specialist
• Confirmed MASH diagnosis by FibroScan_VCTE, ultrasound elastography, MRE, and liver_biopsy, fibrosis stage F2 to F3

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Documentation that prescriber is a Hepatologist or Gastroenterologist
• Patient age documentation (>=18 years)
• MASH diagnosis with fibrosis stage F2 or F3 confirmed by transient elastography, ultrasound elastography, MRI elastography, and/or liver biopsy
• Documentation that fibrosis is persistent (F2/F3) and refractory to at least 3 months of lifestyle changes and/or structured weight loss program
• Documentation of absence of significant alcohol consumption within 1 year (females <=7 drinks/week [98g]; males <=14 drinks/week [196g])
• Documentation of absence of regular use of drugs associated with MAFLD
• Documentation of absence of active serious medical disease with life expectancy <2 years
• ALT/AST levels confirming not >5x ULN due to other chronic liver disease
• Confirmation of absence of pregnancy/breastfeeding/planning pregnancy
• Confirmation of no personal or family history of MTC or MEN2
• Confirmation of no prior or current pancreatitis or gallbladder disease/gallstones
• Confirmation of no bariatric surgery within past 6 months

Approval and renewal

• Initial approval: 12 months
• Renewal: every 12 months
• To renew, the plan looks for Clinically significant benefit defined as: NAFLD Activity Score (NAS) decreased by at least 2 points from baseline OR reduction in fibrosis stage. AND specialist follow-up in the last 12 months. Initial criteria (e.g., F2/F3 fibrosis documentation, alcohol consumption exclusion, specialist prescriber requirement) are NOT explicitly re-verified for existing members who have previously met criteria.

Not covered when

• Bariatric surgery within the last 6 months
• Significant alcohol consumption within 1 year (>7 drinks/week [>98g] for females; >14 drinks/week [>196g] for males)
• Regular use of drugs associated with MAFLD (amiodarone, methotrexate, systemic glucocorticoids >5mg/day, tamoxifen, high-dose estrogen, anabolic steroids [except testosterone replacement], valproic acid, known hepatotoxins)
• Active serious medical disease with life expectancy <2 years
• ALT/AST >5x ULN likely due to other chronic liver disease
• Breastfeeding
• Planning to become pregnant
• Personal or family history of MTC or MEN2
• Prior or current pancreatitis or gallbladder disease/gallstones
• Pregnancy
• Bariatric surgery

Policy note: Applies to Wegovy injectable ONLY — oral tablets are NOT covered for MASH indication. Fibrosis confirmation methods include transient elastography (FibroScan), ultrasound elastography, MRI elastography, and/or liver biopsy. No explicit lookback period stated for confirmatory testing. Continuation requires specialist follow-up within last 12 months plus documented clinical benefit (NAS decrease >=2 points or fibrosis stage reduction).

Policy effective June 2, 2026 · verified June 5, 2026 · source: hmo-exchange-prior-authorization-criteria-en.pdf

What you need to qualify

• Age 18 and older
• 3 months of a documented diet and exercise program
• Prescribed by or in consultation with a specialist
• Confirmed MASH diagnosis by FibroScan_VCTE, ultrasound elastography, MRE, and liver_biopsy, fibrosis stage F2 to F3

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Documentation that prescriber is a Hepatologist or Gastroenterologist
• Patient age documentation (>=18 years)
• MASH diagnosis with fibrosis stage F2 or F3 confirmed by transient elastography, ultrasound elastography, MRI elastography, and/or liver biopsy
• Documentation that fibrosis is persistent (F2/F3) and refractory to at least 3 months of lifestyle changes and/or structured weight loss program
• Documentation of absence of significant alcohol consumption within 1 year (females <=7 drinks/week [98g]; males <=14 drinks/week [196g])
• Documentation of absence of regular use of drugs associated with MAFLD
• Documentation of absence of active serious medical disease with life expectancy <2 years
• ALT/AST levels confirming not >5x ULN due to other chronic liver disease
• Confirmation of absence of pregnancy/breastfeeding/planning pregnancy
• Confirmation of no personal or family history of MTC or MEN2
• Confirmation of no prior or current pancreatitis or gallbladder disease/gallstones
• Confirmation of no bariatric surgery within past 6 months

Approval and renewal

• Initial approval: 12 months
• Renewal: every 12 months
• To renew, the plan looks for Clinically significant benefit defined as: NAFLD Activity Score (NAS) decreased by at least 2 points from baseline OR reduction in fibrosis stage. AND specialist follow-up in the last 12 months. Initial criteria (e.g., F2/F3 fibrosis documentation, alcohol consumption exclusion, specialist prescriber requirement) are NOT explicitly re-verified for existing members who have previously met criteria.

Not covered when

• Bariatric surgery within the last 6 months
• Significant alcohol consumption within 1 year (>7 drinks/week [>98g] for females; >14 drinks/week [>196g] for males)
• Regular use of drugs associated with MAFLD (amiodarone, methotrexate, systemic glucocorticoids >5mg/day, tamoxifen, high-dose estrogen, anabolic steroids [except testosterone replacement], valproic acid, known hepatotoxins)
• Active serious medical disease with life expectancy <2 years
• ALT/AST >5x ULN likely due to other chronic liver disease
• Breastfeeding
• Planning to become pregnant
• Personal or family history of MTC or MEN2
• Prior or current pancreatitis or gallbladder disease/gallstones
• Pregnancy
• Bariatric surgery

Policy note: Applies to Wegovy injectable ONLY — oral tablets are NOT covered for MASH indication. Fibrosis confirmation methods include transient elastography (FibroScan), ultrasound elastography, MRI elastography, and/or liver biopsy. No explicit lookback period stated for confirmatory testing. Continuation requires specialist follow-up within last 12 months plus documented clinical benefit (NAS decrease >=2 points or fibrosis stage reduction).

Policy effective June 2, 2026 · verified June 5, 2026 · source: hmo-exchange-prior-authorization-criteria-en.pdf