Kentucky Medicaid coverage for Wegovy (Liver

Medicaid

Covered with requirements

What you need to qualify

Age 18 and older
6 months of a documented diet and exercise program
Prescribed by or in consultation with a specialist
Confirmed MASH diagnosis by liver_biopsy, FIB-4, FibroScan_VCTE, and ELF_test, fibrosis stage F2 to F3
Lab results confirming eligibility from the last 6 months
Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

MASH — Initial Approval

All of:

Request is NOT for Wegovy tablet (injection formulation only)
Patient age >= 18 years
Diagnosis of MASH (also known as NASH) with moderate to advanced liver fibrosis (stages F2 to F3)
Prior trial of diet, exercise, and lifestyle modification; patient will continue if approved
Prescribed by or in consultation with a gastroenterologist or hepatologist
Prescriber attests patient does not have excessive alcohol consumption
No history of type 2 diabetes
No evidence of cirrhosis
No hepatic decompensation
No hepatocellular carcinoma (HCC)
Not pregnant, breastfeeding, or intending to become pregnant without highly effective contraception
Requested dose does not exceed maximum FDA-approved dose
Not used in combination with another GLP-1 or dual GLP-1/GIP receptor agonist

Plus any one of:

Liver biopsy within the last 3 years confirming F2-F3 fibrosis
FIB-4 index > 2.67 within the last 6 months
FIB-4 index 1.3 to 2.67 with sequential VCTE or ELF test within the last 6 months

Documentation to bring

Confirmation that request is for injectable Wegovy (not tablet formulation)
Documentation of MASH/NASH diagnosis with fibrosis stage F2 or F3, confirmed by one of: liver biopsy within past 3 years, FIB-4 index > 2.67 within past 6 months, or FIB-4 index 1.3–2.67 with VCTE or ELF test within past 6 months
Documentation of prior trial of diet, exercise, and lifestyle modification
Prescription from or documentation of consultation with a gastroenterologist or hepatologist
Prescriber attestation that patient does not have excessive alcohol consumption
Attestation that patient does not have history of type 2 diabetes, cirrhosis, hepatic decompensation, or HCC

Quantity limits

all strengths — pen injector — 4 pens per 28 days

Approval and renewal

Initial approval: 6 months
Renewal: every 6 months
To renew, the plan looks for Prescriber must submit clinical documentation of clinical benefit compared to baseline, confirmed by at least one of: liver biopsy improvement, reduction in steatohepatitis (NAS score reduction), reduction in liver fibrosis (NASH CRN fibrosis scale reduction), reduction in steatosis, reduction in lobular inflammation, or reduction in ballooning. Exclusions (no T2DM history, no cirrhosis, no hepatic decompensation, no HCC, no pregnancy/breastfeeding) are re-verified at renewal. MASH fibrosis confirmation (biopsy/FIB-4/VCTE/ELF) and specialist requirement are NOT re-verified at renewal.

Not covered when

Wegovy tablet formulation is not covered for MASH (injection only)
History of type 2 diabetes
Evidence of cirrhosis
Hepatic decompensation
Hepatocellular carcinoma (HCC)
Breastfeeding
Female of child-bearing potential not using highly effective contraception
Concurrent use of another GLP-1 or dual GLP-1/GIP receptor agonist
Excessive alcohol consumption
Pregnancy

Policy note: This is a Kentucky Medicaid PA policy administered by MedImpact. The MASH indication explicitly excludes the tablet formulation of Wegovy — injection only. Fibrosis confirmation pathways include: (1) liver biopsy within 3 years, (2) standalone FIB-4 > 2.67 within 6 months, or (3) FIB-4 1.3–2.67 combined with VCTE or ELF within 6 months. Specialist (gastroenterologist or hepatologist) prescribing or consultation is required. Alcohol limit is not quantified in grams — policy uses 'excessive alcohol consumption' without specifying a threshold. Copyright 2025 MedImpact Healthcare Systems.

verified June 4, 2026 · source: wegovy_pa_criteria_1.3.2026.pdf

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