Kaiser Permanente Northwest coverage for Wegovy (Liver Disease (MASH))

What you need to qualify

• Age 18 and older
• BMI of 30 or higher
• BMI of 27 or higher with a weight-related condition (T2DM, HTN, and dyslipidemia)
• Prior trial of another GLP-1 medication (Ozempic) for at least 90 days
• Prior trial of phentermine, diethylpropion, topiramate, Qsymia, and Contrave for at least 3 months
• Prescribed by or in consultation with a specialist
• Confirmed MASH diagnosis by FibroScan_VCTE, FibroScan_VCTE, MRE, and liver_biopsy, fibrosis stage F2 to F3

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Diagnosis documentation of metabolic dysfunction-associated steatohepatitis (MASH)
• Documentation of hepatology provider consultation and endorsement of Wegovy use
• Documentation of patient age >= 18 years
• Fibrosis staging documentation (F2 or F3) by FibroScan, ultrasound elastography, MRE, or liver biopsy within the past 12 months — OR documentation of known F2/F3 history while currently on GLP-1 agonist without F4
• Documentation satisfying at least one group (f) pathway: BMI with prior weight loss drug step therapy, OR failed formal weight loss program with hepatology recommendation, OR disease refractory to 7-10% weight loss, OR documentation of current GLP-1 agonist use
• Documentation of failed adequate trial (>= 3 months) of semaglutide (Ozempic) — or inapplicable for Medicare Part D
• Confirmation patient is not taking resmetirom
• Confirmation of no regular use of MASLD-associated drugs
• ALT/AST lab results to confirm not > 5x ULN from other chronic liver disease etiology
• Alcohol consumption history confirming < 7 drinks/week (females) or < 14 drinks/week (males)
• Confirmation of no active serious disease with life expectancy < 2 years
• Confirmation of no personal or family history of MTC or MEN 2

Approval and renewal

• Initial approval: 12 months
• Renewal: every 12 months
• To renew, the plan looks for Continuation requires: (1) no progression to fibrosis F4/cirrhosis; (2) no disease progression (increased fibrosis) after >= 18 months on semaglutide without further hepatology consultation; (3) no regular use of MASLD-associated drugs; (4) adherence to medication, diet, lifestyle, alcohol abstinence, and follow-up labs; (5) no active serious disease with life expectancy < 2 years; AND updated fibrosis staging by FibroScan, ultrasound elastography, MRE, or liver biopsy AND hepatology provider follow-up within 2 years after semaglutide initiation.

Not covered when

• Fibrosis stage F4 (cirrhosis) — unless currently on GLP-1 agonist with known prior F2/F3 and no current F4
• Currently taking resmetirom
• Regular use of drugs associated with MASLD
• ALT/AST > 5x ULN likely from other etiology of chronic liver disease
• Significant alcohol consumption (>= 7 drinks/week females or >= 14 drinks/week males)
• Active serious medical disease with likely life expectancy < 2 years

Policy note: Non-formulary; covered for 12 months per approval cycle. The Ozempic prior trial requirement and the non-Medicare Part D BMI/step-therapy pathway in criterion (f) do NOT apply to Medicare Part D patients. Alcohol limits are specified in drinks per week: 7 for females and 14 for males (approximately 98g/week and 196g/week respectively at ~14g/drink — exact gram values not stated in document). Continuation requires updated fibrosis staging AND hepatology follow-up within 2 years of semaglutide initiation. Specialist (hepatology) is required at both initiation and continuation. Continuation criteria do not re-check the Ozempic prior trial requirement or BMI/step-therapy pathways.

Policy effective February 5, 2026 · verified June 5, 2026 · source: kp-criteria-wegovy-nw-en-commercial.pdf