Connecticut Medicaid coverage for Wegovy (Liver Disease (MASH))

What you need to qualify

• Age 18 and older
• Diagnosis documented with a code
• Confirmed MASH diagnosis by liver_biopsy
• Lab results confirming eligibility
• Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Completed 'Wegovy for MASH Prior Authorization Form'
• Documentation of histologically documented steatohepatitis (liver biopsy)
• NAFLD Activity Score (NAS) >= 4
• Hepatic decompensation or MELD score <= 12
• AST and ALT levels <= 5x upper limit of normal
• Valid ICD-10-CM diagnosis code indicating established MASH (from ctdssmap.com Pharmacy ICD-10-CM-Therapeutic Class Product Diagnosis List)
• PA form must be submitted for each new therapy request and annually thereafter

Approval and renewal

• Renewal: every 12 months

Not covered when

• Type 2 diabetes
• Exclusively for weight management
• Type 1 diabetes

Policy note: Document is a Connecticut Medicaid (HUSKY Health A, C, D) Provider Bulletin effective November 3, 2025. Diagnosis code is required in addition to prior authorization. PA must be submitted for new therapy and annually thereafter. The document does not specify explicit fibrosis staging (F1–F3) but requires histologic confirmation with NAS >= 4 and MELD <= 12. Specific payable ICD-10 codes are published separately on ctdssmap.com. Any PA form submitted without required information will be denied.

Policy effective November 3, 2025 · verified June 3, 2026 · source: Get-Download-File