PacificSource Health coverage for Wegovy (Liver Disease (MASH))
Employer / Commercial Insurance
Covered with requirements
What you need to qualify
Age 18 and older
Prior trial of another GLP-1 medication (Mounjaro, Ozempic, Trulicity, liraglutide, and Rybelsus) for at least 84 days
Prescribed by or in consultation with a specialist
Confirmed MASH diagnosis by FIB-4, FibroScan_VCTE, MRE, and liver_biopsy, fibrosis stage F2 to F3
Lab results confirming eligibility
Qualification 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
To renew, the plan looks for 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
ACA Marketplace
Covered with requirements
What you need to qualify
Age 18 and older
Prior trial of another GLP-1 medication (Mounjaro, Ozempic, Trulicity, liraglutide, and Rybelsus) for at least 84 days
Prescribed by or in consultation with a specialist
Confirmed MASH diagnosis by FIB-4, FibroScan_VCTE, MRE, and liver_biopsy, fibrosis stage F2 to F3
Lab results confirming eligibility
Qualification 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
To renew, the plan looks for 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
