Centene coverage for Wegovy (Liver Disease (MASH))

What you need to qualify

• Age 18 and older
• 6 months of a documented diet and exercise program
• Prior trial of 3 other GLP-1 medications (Ozempic, Rybelsus, Trulicity, and liraglutide (generic Victoza)) for at least 90 days
• Prescribed by or in consultation with a specialist
• Confirmed MASH diagnosis by liver_biopsy, FIB-4, ELF_test, FibroScan_VCTE, and MRE, fibrosis stage F2 to F3

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Diagnosis of MASH (chart documentation)
• Documentation that request is for Wegovy injection formulation
• Documentation that prescriber is a hepatologist or gastroenterologist, or that prescription is in consultation with one
• Age verification >= 18 years
• MASH fibrosis staging (F2 or F3) confirmed by: liver biopsy within last 3 years OR both a serum-based test (FIB-4, NFS, or ELF) AND an imaging-based test (VCTE, MRE, or MRI-PDFF) within the last 6 months
• Prescriber attestation of current standard of care management for T2DM, dyslipidemia, and hypertension
• Documentation of active enrollment in physician-directed weight loss program for at least 6 months
• Confirmation that Wegovy is not prescribed concurrently with Rezdiffra
• For concurrent T2DM: documentation of >= 3-month trial each of Ozempic/Rybelsus, Trulicity, and liraglutide (generic Victoza) (unless adverse effects or all contraindicated), except IL HIM as of 1/1/2026

Quantity limits

• 0.25mg, 0.5mg, 1mg
• 1.7mg, 2.4mg

Approval and renewal

• Initial approval: 6 months
• Renewal: every 12 months
• To renew, the plan looks for After at least 12 months of therapy, member must show positive response evidenced by at least one of: (1) improvement in fibrosis >= 1 stage from baseline with no worsening of MASH (no worsening of hepatocellular ballooning, lobular inflammation, or steatosis); (2) resolution of MASH with no worsening of fibrosis; or (3) no increase in fibrosis stage and no worsening of MASH from baseline. Maintenance dose >= 1.7 mg/week required. Standard of care for concomitant conditions re-verified. Prior GLP-1 step therapy NOT re-checked at continuation and staying on a maintenance dose of at least 1.7 mg.

Not covered when

• Cirrhotic MASH (noncirrhotic only per FDA indication)
• Concomitant use with Rezdiffra (resmetirom)
• Concomitant use with other semaglutide-containing products
• Concomitant use with any other GLP-1 receptor agonist
• Wegovy tablets are not approved for MASH indication (injection only)
• Personal or family history of medullary thyroid carcinoma (MTC) or MEN 2 (contraindication)
• Known hypersensitivity to semaglutide or excipients
• Intolerance due to common GI adverse effects of GLP-1 class is NOT acceptable justification for bypassing step therapy

Exceptions

• Illinois: Step therapy requirements for members with concurrent T2DM do not apply for Illinois HIM requests as of 1/1/2026 per IL HB 5395

Policy note: MASH is defined as >= 5% hepatic steatosis with inflammation and hepatocyte injury (ballooning), with or without fibrosis. Fibrosis confirmation methods include combined scores: FAST score (FibroScan + AST), MAST score (MRI-PDFF + MRE + AST), MEFIB score (FIB-4 + MRE). Wegovy injection only — tablets are NOT approved for MASH. Continued FDA approval for MASH indication may be contingent on confirmatory trial verification. Biopsy lookback was revised from 6 months to 3 years per AASLD guidance in the 09.09.25 revision.

Policy effective June 1, 2024 · verified June 2, 2026 · source: CP.PMN.295.pdf