Michigan Medicaid coverage for Wegovy (Liver

Medicaid

Covered with requirements

What you need to qualify

Age 18 and older
BMI of 27 or higher
Confirmed MASH diagnosis, fibrosis stage F2 to F3

Qualification pathways

You can qualify through any one of these.

Initial Approval — Wegovy for MASH

All of:

Prescriber attests patient will not use Wegovy concurrently with another GLP-1 agonist
Prescriber attests patient will not use Wegovy concurrently with a non-GLP-1 weight loss medication
Prescriber attests patient will not use Wegovy concurrently with a DPP-4 inhibitor (alogliptin, linagliptin, saxagliptin, or sitagliptin)
Patient >= 18 years of age
Prescriber attests patient has initial BMI >= 27 kg/m²
Prescriber attests patient has noncirrhotic MASH (formerly NASH) with moderate to advanced liver fibrosis (F2 to F3)
For patients with an eating disorder: prescriber attests treatment has been optimized and confirms safety and appropriateness
Prescriber attests metabolic or other reasons for obesity/symptoms have been ruled out or diagnosed and treated (e.g., thyroid dysfunction, diabetes, sleep apnea)
Prescriber attests absence of contraindications including pregnancy, lactation, personal or family history of medullary thyroid cancer or multiple endocrine neoplasia type II
Prescriber attests medication is part of a total treatment plan including diet and exercise/activity as appropriate
Prescriber attests patient has been informed weight may return upon cessation unless lifestyle changes are permanently adopted

Renewal Approval — Wegovy for MASH

All of:

Prescriber attests patient is currently established on the medication
Prescriber attests patient continues to have noncirrhotic MASH with moderate to advanced liver fibrosis (F2 to F3)
Clinical documentation demonstrating patient has maintained >= 5% weight loss from baseline weight at initiation of therapy

Documentation to bring

Prescriber attestation that patient will not use Wegovy concurrently with another GLP-1 agonist
Prescriber attestation that patient will not use Wegovy concurrently with a non-GLP-1 weight loss medication
Prescriber attestation that patient will not use Wegovy concurrently with a DPP-4 inhibitor
Documentation of patient age >= 18 years
Baseline BMI documentation (>= 27 kg/m²)
Prescriber attestation of noncirrhotic MASH diagnosis with moderate to advanced fibrosis (F2 to F3)
Prescriber attestation regarding eating disorder status (if applicable: treatment optimized and safety confirmed)
Prescriber attestation that metabolic/other causes of obesity have been ruled out or treated
Prescriber attestation of absence of contraindications (pregnancy, lactation, personal/family history of medullary thyroid cancer or MEN2)
Prescriber attestation that medication is part of a total treatment plan including diet and exercise
Prescriber attestation that patient has been counseled on weight regain risk upon cessation
[Renewal] Clinical documentation of current weight showing >= 5% weight loss from baseline

Quantity limits

0.25 mg/0.5 mL, 0.50 mg/0.5 mL, 1 mg/0.5 mL — 2 mL (4 pens) per 28 days
1.7 mg/0.75 mL, 2.4 mg/0.75 mL — 3 mL (4 pens) per 28 days

Approval and renewal

Initial approval: 6 months
Renewal: every 6 months
To renew, the plan looks for at least 5% weight loss from the starting weight and Patient must have maintained a weight loss of >= 5% from baseline weight at initiation of therapy. Prescriber must also attest that patient is currently established on the medication and continues to have noncirrhotic MASH with moderate to advanced liver fibrosis (F2 to F3). Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

Lactation
Personal or family history of medullary thyroid cancer
Multiple endocrine neoplasia type II (MEN2)
Concurrent use of another GLP-1 agonist
Concurrent use of a non-GLP-1 weight loss medication
Concurrent use of a DPP-4 inhibitor (alogliptin, linagliptin, saxagliptin, or sitagliptin)
Pregnancy

Policy note: This policy is specific to Michigan Medicaid and is managed by Prime Therapeutics. The document covers Wegovy ONLY for the MASH indication. No fibrosis confirmation method (e.g., FIB-4, FibroScan, biopsy) is specified — only a prescriber attestation of noncirrhotic MASH with F2-F3 fibrosis is required. The policy does not require cirrhosis to be absent per a specific test but does specify 'noncirrhotic.' MDHHS recommends (but does not require) a diabetes prevention program. The renewal requires documentation of >= 5% weight loss from baseline but does not re-verify all initial criteria (e.g., BMI threshold and concurrent medication restrictions are framed as initial attestations).

Policy effective July 1, 2026 · verified June 4, 2026 · source: MIRx_clinical_criteria.pdf

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