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Regence · Liver Disease (MASH)

Regence coverage for Wegovy (Liver Disease (MASH))

Employer / Commercial Insurance

Covered with requirements

What you need to qualify

  • 6 months of a documented diet and exercise program
  • Prescribed by or in consultation with a specialist
  • Confirmed MASH diagnosis by liver_biopsy, FibroScan_VCTE, ELF_test, and MRE, fibrosis stage F2 to F3

Qualification pathways

You can qualify through any one of these.

Noncirrhotic MASH with F2 or F3 fibrosis

All of:

  • Diagnosis of MASH (noncirrhotic metabolic dysfunction-associated steatohepatitis / NASH) established by or in consultation with a gastroenterologist or hepatologist
  • Fibrosis stage F2 or F3 confirmed by one of the accepted methods (liver biopsy, VCTE, ELF score, or MRE)
  • Attestation medication will be used with lifestyle modification

Documentation to bring

  • Clinical documentation (e.g., chart notes) confirming diagnosis of MASH established by or in consultation with a gastroenterologist or hepatologist
  • Documentation of Stage F2 or F3 fibrosis confirmed by one of: liver biopsy, vibration-controlled transient elastography (VCTE), Enhanced Liver Fibrosis (ELF) score, or magnetic resonance elastography (MRE)
  • Attestation that medication will be used with lifestyle modification
  • For continuation: attestation of clinical benefit such as stability or improvement of liver fibrosis stage relative to baseline

Quantity limits

  • all strengths - injection — 4 pens per 28 days
  • all strengths - tablet — 30 tablets per 30 days

Approval and renewal

  • Initial approval: 12 months
  • Renewal: every 12 months
  • To renew, the plan looks for Attestation that the medication is providing clinical benefit, such as stability or improvement of liver fibrosis stage relative to baseline.

Not covered when

  • Cirrhotic MASH (policy specifies noncirrhotic only)
  • Co-administration with other weight loss medications considered investigational
  • Diabetic ketoacidosis (DKA)
  • Type 1 diabetes

Policy note: MASH indication is NOT subject to the weight loss benefit contract language restriction — it qualifies under standard coverage without the obesity benefit rider requirement. Prior to 6/4/2026 revision, there was a requirement for prior failure to achieve weight loss goals with diet and exercise; this has been removed. Specialist (gastroenterologist or hepatologist) diagnosis or consultation is explicitly required. No lookback periods specified for confirmatory testing. Wegovy HD added at parity 6/4/2026. BMI >= 27 kg/m2 was observed in the ESSENCE trial population but is not listed as a policy coverage criterion.

Policy effective July 15, 2026 · verified July 16, 2026 · source: dru787reg.pdf

ACA Marketplace

Covered with requirements

What you need to qualify

  • Prescribed by or in consultation with a specialist
  • Confirmed MASH diagnosis by liver_biopsy, FIB-4, FibroScan_VCTE, ELF_test, and MRE, fibrosis stage F2 to F3

Qualification pathways

You can qualify through any one of these.

Noncirrhotic MASH with F2-F3 fibrosis

All of:

  • Diagnosis of noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH/NASH) established by or in consultation with a gastroenterologist or hepatologist
  • Stage F2 or F3 fibrosis confirmed by liver biopsy OR at least two of the following non-biopsy methods: FIB-4 score consistent with F2 or F3 fibrosis adjusted for age, Vibration-controlled transient elastography (VCTE), Enhanced liver fibrosis (ELF) score, Magnetic resonance elastography (MRE)
  • Attestation of failure to achieve weight-loss goals with diet and exercise
  • Attestation that medication will be used with lifestyle modification

Documentation to bring

  • Clinical documentation (such as chart notes) of MASH/NASH diagnosis established by or in consultation with a gastroenterologist or hepatologist
  • Documentation confirming noncirrhotic status
  • Fibrosis staging confirmation: liver biopsy showing F2 or F3 fibrosis OR at least two of the following: FIB-4 score consistent with F2/F3 adjusted for age, VCTE result, ELF score, MRE result
  • Attestation of failure to achieve weight-loss goals with diet and exercise

Quantity limits

  • all strengths - injection — 4 pens/28 days
  • all strengths - tablet — 30 tablets/30 days

Approval and renewal

  • Initial approval: 12 months
  • Renewal: every 12 months
  • To renew, the plan looks for Attestation that the medication is providing clinical benefit, such as stability or improvement of liver fibrosis stage relative to baseline.

Not covered when

  • Cirrhotic MASH (policy specifies noncirrhotic only)
  • Co-administration with other medications for obesity or overweight (Contrave, Qsymia) is considered investigational

Policy note: MASH criteria were added to this policy effective 1/22/2026. The MASH indication does not appear to require the weight loss benefit rider. Fibrosis must be Stage F2 or F3 (not F1 or F4/cirrhotic). When biopsy is not used, at least TWO of the four non-biopsy tests must confirm F2/F3 fibrosis. The SELECT trial (BMI >=27 kg/m2) informs the MASH evidence base, but no explicit BMI threshold is stated in the MASH coverage criteria. Policy notes AASLD guidelines endorse weight-loss and comorbidity management for MASH.

Policy effective March 15, 2026 · verified June 3, 2026 · source: dru787reg.pdf

All Wegovy policies under Regence · Check your card