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Kaiser Permanente Mid-Atlantic · Liver Disease (MASH)

Kaiser Permanente Mid-Atlantic coverage for Wegovy (Liver Disease (MASH))

Employer / Commercial Insurance

Covered with requirements

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.

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
  • 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

ACA Marketplace

Covered with requirements

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.

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
  • 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

Federal Employee Program

Covered with requirements

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.

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
  • 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

All Wegovy policies under Kaiser Permanente Mid-Atlantic · Check your card