Applies to Employer and ACA Marketplace plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
MASH Initial Approval
All of:
- Diagnosis of noncirrhotic NASH or MASH with moderate to advanced (F2 to F3) liver fibrosis confirmed by one of: FAST score, MAST score, MEFIB (FIB-4 ≥1.6 and MRE ≥3.3 kPa), or liver biopsy
- Other causes for liver steatosis have been ruled out (alcohol-associated liver disease, chronic hepatitis C, Wilson disease, drug-induced liver disease)
- Baseline lab values for AST and ALT documented
- Documented treatment failure (or intolerable adverse event) with at least 12 weeks of one of: Mounjaro, Ozempic, Trulicity, liraglutide, or Rybelsus
- Documentation of abstinence from alcohol consumption
- Documentation of comprehensive comorbidity management including: diet and exercise for weight management, and medications to manage associated comorbid conditions (thyroid disease [must not have active disease], diabetes, dyslipidemia, hypertension, or cardiovascular conditions)
- Prescribed by or in consultation with a gastroenterologist or hepatologist
Documentation to bring
- Diagnosis of noncirrhotic MASH/NASH confirmed by one of: FAST score, MAST score, MEFIB (FIB-4 ≥1.6 and MRE ≥3.3 kPa), or liver biopsy — must demonstrate F2-F3 fibrosis
- Documentation that other causes of liver steatosis have been ruled out (alcohol-associated liver disease, chronic hepatitis C, Wilson disease, drug-induced liver disease)
- Baseline AST and ALT lab values
- Documentation of treatment failure or intolerable adverse event with at least 12 weeks of one of: Mounjaro, Ozempic, Trulicity, liraglutide, or Rybelsus
- Documentation of abstinence from alcohol consumption
- Documentation of comprehensive comorbidity management (diet/exercise for weight management; medications for thyroid disease, diabetes, dyslipidemia, hypertension, or cardiovascular conditions as applicable)
- Prescriber attestation or consultation note from gastroenterologist or hepatologist
- For reauthorization: documentation of disease responsiveness (improvement or stability in ALT/AST or fibrosis by non-invasive test)
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- Renewal: Documentation of disease responsiveness to therapy based on improvements or stability in laboratory results (such as ALT and AST) or fibrosis as evaluated by a non-invasive test. Prior GLP-1 failure, abstinence from alcohol, and specialist consultation are not explicitly re-verified at reauthorization.
Not covered when
- Cirrhotic MASH (must be noncirrhotic)
- Active thyroid disease
- Must not have other causes of liver steatosis (alcohol-associated liver disease, chronic hepatitis C, Wilson disease, drug-induced liver disease)
Policy note: MASH confirmation must use ONE of: (1) FAST score from FibroScan-AST, (2) MAST score from MRI-PDFF + MRE + serum AST, (3) MEFIB index (FIB-4 ≥1.6 AND MRE ≥3.3 kPa), or (4) liver biopsy. Liver biopsy is also required if non-invasive testing is inconclusive or other causes of liver disease have not been ruled out. The prior GLP-1 trial requirement specifies 12 weeks (84 days). The policy explicitly excludes use for weight loss or type 1/type 2 diabetes without a qualifying MACE or MASH diagnosis. No lookback periods are specified for the confirmation tests. No explicit alcohol gram limits are stated; abstinence is required.
Policy effective June 22, 2026 · verified June 10, 2026 · source: Cw577pv8jf · View policy document (PDF)