Employer / Commercial Insurance
Depends on your plan's benefitCovered only for select plans with specific benefit language allowing coverage of drugs for weight loss management or weight-related comorbidities; drugs for weight loss management are a standard exclusion for most benefit plans
What you need to qualify
- Age 18 and older
- 6 months of a documented diet and exercise program
- Prescribed by or in consultation with a specialist
- Confirmed MASH diagnosis by liver_biopsy, FAST (FibroScan-AST), MAST (MRI-PDFF + MRE + AST), and MEFIB (MRE + FIB-4), fibrosis stage F2 to F3
Qualification pathways
You can qualify through any one of these.
MASH Initial Approval
All of:
- Member has a diagnosis of MASH with moderate to advanced liver fibrosis consistent with stages F2 to F3, confirmed by liver biopsy, FAST (FibroScan-AST), MAST (MRI-PDFF + MRE + AST), or MEFIB (MRE + FIB-4)
- Requested medication is prescribed by or in consultation with a gastroenterologist, hepatologist, cardiometabolic specialist, or primary care physician in consultation with any of the listed specialists
- Member does not have evidence of cirrhosis, hepatic decompensation, or hepatocellular carcinoma
- Requested medication will be used in conjunction with healthy lifestyle modifications (e.g., dietary or caloric restriction, exercise, behavioral support, community-based program)
MASH Continuation
All of:
- Member is requesting medication for continuation of therapy for MASH
- Member has achieved or maintained a positive clinical response (e.g., improvement in liver function such as reduction in ALT, reduction of liver fat content by imaging such as MRI-PDFF or FibroScan CAP)
- Member does not have evidence of cirrhosis, hepatic decompensation, or hepatocellular carcinoma
- Requested medication will be used in conjunction with healthy lifestyle modifications
Documentation to bring
- Chart notes or medical records documenting clinical findings supporting the diagnosis of MASH
- Documentation of liver fibrosis staging F2-F3 confirmed by liver biopsy, FAST score, MAST score, or MEFIB score
- Documentation that medication is prescribed by or in consultation with a gastroenterologist, hepatologist, cardiometabolic specialist, or PCP in consultation with listed specialists
- Documentation that member does not have evidence of cirrhosis, hepatic decompensation, or hepatocellular carcinoma
- Documentation of positive clinical response for continuation (e.g., reduction in ALT, reduction of liver fat by MRI-PDFF or FibroScan CAP)
Quantity limits
- All strengths — 4 pens
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- To renew, the plan looks for Member has achieved or maintained a positive clinical response (e.g., improvement in liver function such as reduction in ALT, reduction of liver fat content by imaging such as MRI-PDFF or FibroScan CAP). No re-verification of specialist prescribing or fibrosis confirmation methods required at continuation.
Not covered when
- Cirrhosis
- Hepatic decompensation
- Hepatocellular carcinoma
- Plans without specific benefit language allowing weight loss drug coverage
Policy note: MASH indication applies only to Wegovy (semaglutide injection), not Wegovy HD or Wegovy tablet (which are not listed under section VII). Fibrosis confirmation methods accepted: liver biopsy, FAST (FibroScan-AST), MAST (derived from MRI-PDFF + MRE + AST), and MEFIB (MRE combined with FIB-4 index). No lookback periods specified for confirmation tests. The T2DM exclusion that applies to weight_loss and cv_risk_reduction indications does NOT apply to MASH. Quantity limit applies to injection formulation only; semaglutide tablet quantity limit is 30 tabs/30 days.
Policy effective May 19, 2026 · verified June 3, 2026 · source: Drugs-for-weight-loss-management.pdf