I.  ONE of the following: 

A.  ALL of the following: 

2.  The patient has a diagnosis of noncirrhotic nonalcoholic steatohepatitis (NASH) or metabolic dysfunction associated steatohepatitis (MASH) AND 

3.  The patient has stage F2 or F3 fibrosis as confirmed by ONE of the following (prior to therapy with the requested agent): (medical records required) 

i.  A liver biopsy within the past 2 years OR 

ii.  Vibration-controlled transient elastography (VCTE) OR 

iii.  Enhanced liver fibrosis (ELF) score OR 

iv.  Magnetic resonance elastography (MRE) AND 

4.  ONE of the following: 

i.  The requested agent is Wegovy OR 

ii.  The requested agent is Rezdiffra AND BOTH of the following: 

.  of the following: 

i.  A BMI less than or equal to 23kg/m^2 if the patient is of South Asian, Southeast Asian, or East Asian descent (medical records required) OR 

ii.  A BMI less than or equal to 25kg/m^2 (medical records required) OR 

iii.  Has tried and had an inadequate response after 72 weeks of therapy with Wegovy OR 

iv.  tried and had an inadequate response after 72 weeks of therapy with another subcutaneous GLP-1 agent for the treatment of the requested indication OR 

v.  Has an intolerance or hypersensitivity to therapy with Wegovy OR 

vi.  Provider submits documentation that patient has condition or comorbidity that are unable to trial Wegovy therapy OR 

vii.  Has an FDA labeled contraindication to Wegovy AND 

b.  BOTH of the following: 

The patient is currently on a weight management regimen of a low-calorie diet, increased physical activity, and behavioral modifications AND 

The patient will continue the weight management regimen in combination with the requested agent AND 

5.  ONE of the following 

i.  If the patient’s sex is female then the patient’s alcohol consumption is less than 20gm/day (NOTE: one standard alcoholic drink contained roughly 14gm of pure alcohol, which is found in 12 oz. of regular beer, 5oz of wine, or 1.5oz of distilled spirits) (medical records required) OR 

ii.  If the patient’s sex is male then the patient’s alcohol consumption is less than 30gm/day (NOTE: one standard alcoholic drink contained roughly 14gm of pure alcohol, which is found in 12 oz. of regular beer, 5oz of wine, or 1.5oz of distilled spirits) (medical records required) AND 

6.  The patient is being monitored and/or treated for any comorbid conditions (e.g., cardiovascular disease, diabetes, dyslipidemia, hypertension) AND 

B.  The patient has another FDA labeled indication for the requested agent AND 

II.  If the patient has an FDA labeled indication, then ONE of the following: 

A.  The patient’s age is within FDA labeling for the requested indication for the requested agent OR 

B.  There is support for using the requested agent for the patient’s age for the requested indication AND 

III.  The patient does NOT have ANY of the following: (medical records required) 

A.  Decompensated cirrhosis 

B.  Moderate to severe hepatic impairment (Child-Pugh Class B or C) 

.  CAny other liver disease (e.g. Wilson’s Disease, hepatocellular carcinoma, hepatitis) AND 

IV. .  The prescriber is a specialist in the area of the patient’s diagnosis (e.g. gastroenterologist or hepatologist) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis  AND 

V.  The patient does NOT have any FDA labeled contraindications to the requested agent. 

VI.  The requested quantity (dose) does NOT exceed the program quantity limit OR 

VII.  The requested quantity (dose) exceeds the program quantity limit AND ONE of the following: 

A.  BOTH of the following: 

1.  The requested agent does NOT have a maximum FDA labeled dose for the requested indication AND 

2.  There is support for therapy with a higher dose for the requested indication OR 

B.  BOTH of the following: 

1.  The requested quantity (dose) does NOT exceed the maximum FDA labeled dose for the requested indication AND 

2.  There is support for why the requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does NOT exceed the program quantity limit 

I.  The patient has been previously approved for the requested agent through the plan’s Prior Authorization process (Note: patients not previously approved for the requested agent will require initial evaluation review) AND 

II.  ONE of the following: 

A.  The patient has a diagnosis of noncirrhotic nonalcoholic steatohepatitis (NASH) or metabolic dysfunction associated steatohepatitis (MASH) (medical records required) AND 

1.  ONE of the following: 

i.  If the patient’s sex is female then the patient’s alcohol consumption is less than 20gm/day (NOTE: one standard alcoholic drink ii.  contained roughly 14gm of pure alcohol, which is found in 12 oz. of regular beer, 5oz of wine, or 1.5oz of distilled spirits) (medical records required) OR 

If the patient’s sex is male then the patient’s alcohol consumption is less than 30gm/day (NOTE: one standard alcoholic drink contained roughly 14gm of pure alcohol, which is found in 12 oz. of regular beer, 5oz of wine, or 1.5oz of distilled spirits) (medical records required) AND 

2.  BOTH of the following: 

i.  The patient is currently on a weight management regimen of a low-calorie diet, increased physical activity, and behavioral modifications AND 

ii.  The patient will continue the weight management regimen in combination with the requested agent OR 

III.  The patient has had clinical benefit with the requested agent AND 

IV.  The patient does NOT have ANY of the following: (medical records required) 

A.  Decompensated cirrhosis 

B.  Moderate to severe hepatic impairment (Child-Pugh Class B or C) 

C.  Any other liver disease (e.g., Wilson’s disease, hepatocellular carcinoma, hepatitis) AND 

V.  The prescriber is a specialist in the area of the patient’s diagnosis (e.g., hepatologist, gastroenterologist), or the prescriber has consulted with a specialist in the area of the patient’s diagnosis AND 

VI.  The patient does NOT have any FDA labeled contraindications to the requested agent