Medicaid
Covered with requirementsWhat you need to qualify
- Diagnosis documented with a code
- Prescribed by or in consultation with a specialist
- Confirmed MASH diagnosis by liver_biopsy, FibroScan_VCTE, and MRE, fibrosis stage F2 to F3
- Lab results confirming eligibility
Qualification pathways
You can qualify through any one of these.
MASH with moderate to advanced fibrosis
All of:
- Moderate to advanced liver fibrosis consistent with stages F2 to F3
- Fibrosis confirmed by biopsy OR non-invasive tests (e.g., FibroScan or MRE + MRI-PDFF)
- Agent prescribed by or in conjunction with a hepatologist or gastroenterologist
Documentation to bring
- Member's relevant medical records and/or pharmacy profile
- Appropriate baseline diagnostic and safety biopsy, laboratory, and/or noninvasive test results confirming F2-F3 fibrosis
- Documentation that agent is prescribed by or in consultation with a hepatologist or gastroenterologist (name and NPI of consulting provider required)
- Documentation of reduced calorie diet
- Documentation of increased physical activity
- Confirmation that member is NOT currently on another GLP-1 agonist
- Confirmation that member has no contraindicated conditions/medications with requested GLP-1
- Pharmacy claims history or pharmacy profile
Approval and renewal
- Initial approval: 6 months
- Renewal: every 6 months
- To renew, the plan looks for Prescriber must attest that the member continues to derive clinical benefit with the requested agent AND that the member requires ongoing therapy as part of the treatment plan. Resubmission of initial coverage documentation is NOT required at reauthorization.
Not covered when
- Currently on another GLP-1 agonist
- Has a contraindicated condition/disease with the requested GLP-1 agonist
- Currently on a contraindicated medication with the requested GLP-1 agonist
- BMI >= 27 kg/m2 is NOT required (obesity is a risk factor but not a requirement)
Policy note: MASH indication explicitly states BMI >= 27 kg/m2 is NOT a requirement. Fibrosis must be stages F2 to F3 (moderate to advanced). Non-invasive test examples include FibroScan or MRE + MRI-PDFF. Specialist (hepatologist or gastroenterologist) must prescribe or be consulted. Initial authorization up to 6 months in <= 30-day supplies; reauthorization 6 months in <= 90-day supplies.
Policy effective April 20, 2026 · verified June 4, 2026 · source: Pa policy