CurrentAnthemPolicy N/A

Prior Authorization: GLP‑1 Receptor Agonists for Metabolic Dysfunction‑Associated Steatohepatitis (MASH)

This form governs prior authorization requirements for prescribing FDA‑indicated GLP‑1 receptor agonists to Medicaid members with metabolic dysfunction‑associated steatohepatitis (MASH) under Anthem HealthKeepers products in Virginia. It affects prescribers requesting initial or renewal coverage for these medications.

Policy Summary

PayerAnthem

PolicyPrior Authorization: GLP‑1 Receptor Agonists for MASH

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with required documentation and ensure the medication is prescribed by or in consultation with a hepatologist, gastroenterologist, or liver disease specialist.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsinitial authorization duration

12 monthsrenewal authorization duration

18+min member age (yrs)

≤9.5%A1C eligibility

≤12MELD screening max

Coverage Criteria for GLP-1 Receptor Agonists (MASH)

Initial Therapy

Covered when ALL of the following are met:

Initial Authorization Criteria: Member is ≥18 years; baseline or recent liver biopsy demonstrates clinically significant MASLD by at least one enumerated histologic criterion (histological evidence of MASH; OR NASH CRN score consistent with fibrosis stage F2 or F3; OR NAFLD activity score ≥4 with ≥1 point in steatosis, lobular inflammation, and hepatocyte ballooning); BMI ≥ 18.5 kg/m2; provider attests individualized healthy lifestyle counseling was provided; A1C is not >9.5%; no known or suspected excessive alcohol consumption; no hepatic decompensation and MELD score ≤12 at screening; no history of pancreatitis, acute suicidal behavior/ideation, personal or family history of medullary thyroid cancer or MEN2; member is not concurrently on another GLP-1 receptor agonist; medication is FDA-indicated and prescribed by or in consultation with a hepatologist, gastroenterologist, or other liver disease specialist.see thresholds

All bullets on the form must be attested to for approval

Continuation Therapy / Renewal

Renewal authorization requires ALL of the following:

Policy Summary

PayerAnthem

PolicyPrior Authorization: GLP‑1 Receptor Agonists for MASH

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Renewal Criteria: Member has experienced clinical improvement on the requested medication; member is being treated with a maintenance dosage of the requested drug; prescriber signature attesting that the information is accurate and verifiable by member records.N/A

Renewals are granted for 12 months

Coverage is conditional and excludes members with certain concurrent therapies or clinical risks. Specifically, a member is ineligible if they are concurrently using another GLP-1 receptor agonist or have known or suspected excessive alcohol consumption. Members with evidence of hepatic decompensation or a MELD score > 12 at screening are not eligible. Additional exclusionary conditions include a history of pancreatitis, acute suicidal behavior or ideation, or a personal or family history of medullary thyroid cancer or multiple endocrine neoplasia type 2 (MEN2).

If a provider cannot attest to the required clinical eligibility statements on the PA form, the request may be denied. Common reasons a member may be unable to meet attestations include absence of the required histologic evidence for clinically significant MASLD (for example, no biopsy demonstrating MASH, no NASH CRN score consistent with F2–F3 fibrosis, or NAFLD activity score criteria not met), or the presence of any of the disqualifying conditions listed on the form (excessive alcohol use, hepatic decompensation/MELD > 12, pancreatitis, uncontrolled psychiatric risk such as acute suicidal behavior/ideation, or a relevant personal/family cancer syndrome).

Key Eligibility Metrics and Coding

Age — minimum requirement

Minimum ageMember must be 18 years of age or older

Source of age requirementForm checklist item: 'The member is 18 years of age or older'

ApplicabilityRequired for all initial authorization requests

BMI — body mass index threshold

BMI thresholdBMI ≥ 18.5 kg/m2

Source of BMI requirementForm checklist item: 'The member has a BMI ≥ 18.5 kg/m2'

ApplicabilityRequired for all initial authorization requests

A1C — glycemic threshold for eligibility

Glycemic (A1C) thresholdMember must not have an A1C > 9.5% (i.e., A1C ≤ 9.5%)

Source of A1C requirementForm checklist item: 'The member does not have an A1C of >9.5%'

ApplicabilityRequired to meet initial eligibility; uncontrolled diabetes (A1C >9.5%) is an exclusion

MELD score — maximum allowed at screening

Maximum MELD at screeningMember must not have a MELD score > 12 (i.e., MELD ≤ 12)

Source of MELD requirementForm checklist item: 'The member does not have hepatic decompensation or a MELD score of >12 at screening'

ApplicabilityRequired to exclude advanced hepatic decompensation for initial authorization

Provider Requirements, Documentation, and Authorization

Prior Authorization

Prior authorization and prescriber specialty requirement

Prior Authorization Required: Prior authorization is required. Requests must be for FDA‑indicated medications only and must be prescribed by or in consultation with an appropriate specialist (hepatologist, gastroenterologist, or other provider specializing in liver disease).

PA required for FDA‑indicated medications only
Prescriber must be specialist or in consultation with one

Step Therapy

Step therapy

No step therapy sequencing is specified for this therapy in this policy.

Documentation Required

Required documentation for prior authorization

Required documentation for prior authorization includes a fully completed PA form with member demographics (name, Medicaid/ID, DOB, weight), prescriber information (name, NPI, contact), and detailed drug information (name, form, strength, dosing frequency, length of therapy, quantity, day supply). Clinical documentation must support diagnosis and medical necessity, including age, BMI, liver biopsy or validated noninvasive scoring consistent with clinically significant MASLD/MASH (e.g., histology showing MASH, NASH CRN F2–F3, or NAFLD activity score ≥4 with required component scores), documentation of individualized lifestyle counseling, A1C value, alcohol use history, MELD score, absence of pancreatitis, and medication history (including no concurrent GLP‑1 use).

Completed PA form elements: member demographics, prescriber NPI, drug details (name, form, strength, dose, frequency, quantity, day supply)
Clinical documentation: liver biopsy or validated noninvasive scores showing clinically significant MASLD/MASH, BMI, lifestyle counseling note, A1C, alcohol use assessment, MELD score, pancreatitis history, concurrent medication list

Documentation Required

Authorization length and renewal documentation

Authorization length and renewal documentation: Initial authorizations are granted for 6 months. Renewal authorizations are granted for 12 months. For renewals, submit documentation showing clinical improvement on the requested medication and that the member is on a maintenance dosage. Include updated clinical measures and any supporting labs or imaging as appropriate.

Initial authorization duration: 6 months
Renewal authorization duration: 12 months
Renewal requirements: evidence of clinical improvement and being treated at a maintenance dose; include updated clinical documentation

Documentation Required

Form completeness and provider attestations

Form completeness and attestations: Include the prescriber signature and date. By signing, the prescriber attests that the information is accurate and verifiable by member records. Incomplete or unverifiable responses, missing attestations, or failure to answer all questions may result in denial or delay of the PA. Submission of the completed form (fax to 844‑512‑7020) does not guarantee coverage.

Provider must sign and date the form (attestation of accuracy)
Incomplete or unverifiable forms may be denied or delayed
Fax completed form to 844‑512‑7020

Definitions and Specialist Roles

Clinically significant MASLD — acceptable documentation

Histological evidence of MASHDocumented histological evidence of metabolic dysfunction‑associated steatohepatitis (MASH)

NASH CRN fibrosis stageNASH Clinical Research Network score consistent with fibrosis stage F2 or F3

NAFLD activity score criteriaNonalcoholic fatty liver disease activity score ≥4 with ≥1 point in each: steatosis, lobular inflammation, and hepatocyte ballooning

Prescriber specialist — authorized specialists

Authorized prescriber specialtiesHepatologist, gastroenterologist, or other provider specializing in liver disease

Prescriber role for authorizationMedication must be prescribed by or in consultation with one of the authorized specialists

DocumentationPrescriber attestation and signature required on the PA form

Clinical Background

Metabolic dysfunction–associated steatohepatitis (MASH), referenced in this form as clinically significant MASLD, is established by histologic criteria. Documentation must show at least one of the following: histological evidence of MASH; a NASH Clinical Research Network score consistent with fibrosis stage F2 or F3; or a NAFLD activity score ≥ 4 with ≥1 point each for steatosis, lobular inflammation, and hepatocyte ballooning. These histologic thresholds are required to confirm disease severity for consideration of GLP‑1 therapy under this policy.

Revision History

unspecifiedauthorization_duration_specified

Document states initial authorizations are granted for six months and renewals for 12 months.

unspecifiedprior_authorization_and_prescriber_requirement

Form requires FDA‑indicated medications and that they be prescribed by or in consultation with a hepatologist, gastroenterologist, or other liver disease specialist.

unspecifiedrenewal_clinical_requirementsLatest

Renewal requests must document clinical improvement and maintenance dosing, with prescriber attestation and date.