Wegovy (semaglutide) prior authorization for MASH/NASH
Customize your policy alerts
Sign up for all AvMed policy alerts
Know when AvMed releases new policies or updates existing guidance.
Monitor payer policy activity
This form governs pharmacy prior authorization and step-edit requests for Wegovy (semaglutide) when prescribed for metabolic dysfunction-associated steatohepatitis (MASH)/nonalcoholic steatohepatitis (NASH) for AvMed members.
No material clinical or coverage changes in this revision.
Coverage Criteria for Wegovy (semaglutide) — MASH/NASH
Initial Therapy — Covered when ALL of the following are met
Covered when ALL of the following are met
Initial authorization period: 12 months (supporting documentation required).
Submit full test reports; biopsy required if indeterminate.
Verified by chart notes, labs, and/or pharmacy claims; submit CMP and CBC results.
Documentation to rule out other liver diseases and alcohol history must be submitted.
Use of samples to initiate therapy does not satisfy step‑therapy requirements.
Reauthorization — Reauthorization requirements — all must be met
Reauthorization requirements — all must be met
Accepted tests include FibroScan (vibration‑controlled transient elastography), magnetic resonance elastography (MRE), shear wave elastography, or biopsy; reauthorization interval: 6 months.
The policy excludes members with significant alcohol use or advanced liver disease. Specifically, members with alcohol consumption of more than 20 g per day for women and more than 30 g per day for men are exclusionary. In addition, members with documented cirrhosis, hepatic decompensation, or hepatocellular carcinoma are not eligible; supporting documentation must be provided to demonstrate the absence of these conditions.
Concurrent use of another GLP-1 receptor agonist for a different indication is prohibited. The policy explicitly lists examples including Zepbound®, Saxenda®, Mounjaro®, Ozempic®, Trulicity®, and Rybelsus®. For combination therapy of Wegovy® with Rezdiffra®, approval requires submission of documentation showing an insufficient clinical response to Rezdiffra after a 6-month trial (for example, lack of MASH/NASH resolution or no improvement in fibrosis score).
Initial Dosing and Authorization Requirements
Initial dosing and limits
Dosing and initial authorization
Initial authorization length: 12 months.
Prescriptions exceeding quantity limits require justification and supporting documentation.
Continuation / Reauthorization Criteria
Continuation Therapy — Reauthorization criteria
Reauthorization criteria
Reauthorization interval: every 6 months; submit current elastography or biopsy results and supporting documentation (labs, chart notes).
Diagnosis and Scoring Codes
| ICD Code, if applicable (field on form) |
Quantity Limit and Product Details
Provider Actions, Documentation, and Denial Triggers
Prior Authorization Required
Prior authorization is required for Wegovy when prescribed for Metabolic Dysfunction‑Associated Steatohepatitis (MASH/NASH). The prescribing physician must sign and clearly print their name on the PA request form (preprinted stamps are not valid). Fax completed request forms to 1-305-671-0200. Incomplete, incorrect, or illegible information can delay the authorization process.
- Applicable product: Wegovy (semaglutide) for MASH/NASH
- Authorization types: Initial authorization up to 12 months; Reauthorization up to 6 months
Step‑Edit and Sample Policy
Use of manufacturer samples to initiate therapy does not satisfy step‑therapy or prior authorization requirements. Providers must submit a PA request and required supporting documentation regardless of sample use.
- Samples do not replace required PA/step‑edit documentation
Required Supporting Documentation
Providers must submit documentation to support each checked criterion on the PA form. To avoid delays or denials, include all relevant results and records such as liver biopsy reports, elastography or MRE results (within the last 6 months), current CMP and CBC results, documentation of metabolic risk factors (chart notes, labs, pharmacy claims), and records ruling out other causes of liver disease. For combination therapy with Rezdiffra®, include documentation of an inadequate response after a 6‑month trial when applicable.
- Biopsy results (≤ 6 months) documenting fibrosis stage F2 or F3 and NAS ≥4 with scores >1 for steatosis, ballooning, and lobular inflammation
- Elastography (e.g., FibroScan) or MRE results (≤ 6 months) if used to determine fibrosis stage
- If fibrosis staging is indeterminate, submit a liver biopsy
- Current liver function tests (CMP) and CBC results
- Documentation verifying ≥3 metabolic risk factors (chart notes, labs, or pharmacy claims)
- Documentation ruling out other causes of liver disease (viral hepatitis, autoimmune, hemochromatosis, alcohol/drug‑induced, etc.)
- For Rezdiffra® combination therapy: records showing ≥6 months trial and insufficient clinical response
Triggers for Delayed or Denied Authorization
Authorizations may be delayed or denied for incomplete, incorrect, illegible, or missing supporting documentation. Missing physician signature, absent phone/fax contact info, lack of required labs/biopsy/imaging, failure to document specialist involvement (hepatologist/gastroenterologist), or evidence of exclusion criteria (cirrhosis, significant alcohol use, concurrent GLP‑1 therapy) are common denial triggers.
- Missing prescriber signature or printed name (preprinted stamps not valid)
- Incomplete or illegible PA form fields (diagnosis, dosing, weight/date, ICD code)
- Missing or outdated biopsy or elastography/MRE results (>6 months)
- Absent current CMP and CBC test results
- No documentation ruling out other causes of liver disease
- Failure to document member is not cirrhotic and has no hepatic decompensation or hepatocellular carcinoma
- Concurrent use of another GLP‑1 receptor agonist without documentation of discontinuation
- Insufficient documentation of specialist involvement when required (hepatologist or gastroenterologist)
Step Therapy Requirements
| Step | Requirement | Duration | Coverage status |
|---|---|---|---|
| 1 | Documentation of a trial of Rezdiffra with clinical documentation showing insufficient response (e.g., lack of MASH/NASH resolution or no improvement in fibrosis score). | 6 months | Documentation of insufficient response after a 6-month trial is required prior to combination with Wegovy. |
Definitions and Scoring
Background
Metabolic dysfunction-associated steatohepatitis (MASH), also referred to as nonalcoholic steatohepatitis (NASH), is a form of nonalcoholic fatty liver disease characterized by hepatic steatosis with inflammation and variable fibrosis. Staging of fibrosis and assessment of disease activity guide treatment decisions; objective measurements such as elastography (FibroScan, MRE, shear wave elastography) or liver biopsy are used to document resolution or improvement for reauthorization decisions.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.