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Kaiser Permanente Mid-Atlantic

Does Kaiser Permanente Mid-Atlantic cover Wegovy for Liver Disease (MASH)?

Yes. Kaiser Permanente Mid-Atlantic covers Wegovy for liver disease (MASH) with prior authorization. Other policy requirements and your plan's benefits also apply.

Policy document

  • Hmo Exchange Prior Authorization Criteria En

    Kaiser Permanente Mid-Atlantic · PA policy · Employer, ACA Marketplace, and Federal Employee Program

    Effective June 2, 2026. Verified June 5, 2026.

    View PDF Download Original insurer source
  • Employer, ACA Marketplace, and Federal Employee Program: Covered with requirements. See the qualification pathways below.

Earliest policy review June 5, 2026. How we verify · Check your exact plan

Full requirements: Wegovy for Liver Disease (MASH) (3 plan types)

Applies to Employer, ACA Marketplace, and Federal Employee Program plans.

Covered with requirements

Qualification pathways

You can qualify through any one of these.

MASH with F2/F3 fibrosis refractory to lifestyle changes

All of:

  • Prescriber is a Hepatologist or Gastroenterologist
  • Age ≥ 18 years
  • Diagnosis of MASH with fibrosis stage F2 or F3 confirmed by transient elastography, ultrasound elastography, MRI elastography, and/or liver biopsy
  • Persistent fibrosis (F2/F3) refractory to at least 3 months of lifestyle changes and/or structured weight loss program (diet, exercise, medication for weight loss with goal of ≥5% weight loss)
  • No significant alcohol consumption within 1 year (females: ≤7 drinks [98g alcohol]/week; males: ≤14 drinks [196g alcohol]/week)
  • No 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)
  • No active serious medical disease with life expectancy <2 years
  • No ALT/AST >5x ULN likely due to other chronic liver disease
  • Not pregnant, breastfeeding, or planning pregnancy
  • No personal or family history of MTC or MEN2
  • No prior or current pancreatitis or gallbladder disease/gallstones
  • No bariatric surgery within the last 6 months

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
  • Renewal: 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 · View policy document (PDF)

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Questions people ask
Does Kaiser Permanente Mid-Atlantic cover Wegovy?
Yes. Kaiser Permanente Mid-Atlantic covers Wegovy for liver disease (MASH) with prior authorization. Other policy requirements and your plan's benefits also apply.
How long does a Wegovy approval last with Kaiser Permanente Mid-Atlantic?
Liver Disease (MASH) — Applies to Employer, ACA Marketplace, and Federal Employee Program plans. Initial approval: 12 months. Renewal: every 12 months.
What does Kaiser Permanente Mid-Atlantic require to renew Wegovy?
Liver Disease (MASH) — Applies to Employer, ACA Marketplace, and Federal Employee Program plans. 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.
How current is this information?
The oldest review date among the policies on this page is June 5, 2026. Each policy's effective and verification dates appear with its requirements. Confirm current benefits with your plan.

Also under Kaiser Permanente Mid-Atlantic: Mounjaro, Ozempic, Zepbound

Wegovy under other plans: Elevance Health, Maryland Medicaid, Virginia Medicaid, Alabama Medicaid, California Medicaid, Clover Health, Colorado Medicaid, Connecticut Medicaid

All insurance plans · All medications

Summary of Kaiser Permanente Mid-Atlantic's written policy, not a guarantee of coverage. Plans vary by employer and benefit design.