Mississippi Medicaid coverage for Wegovy (Liver

Medicaid

Covered with requirements

What you need to qualify

Prescribed by or in consultation with a specialist
Confirmed MASH diagnosis by FIB-4, FibroScan_VCTE, and liver_biopsy, fibrosis stage F2 to F3

Qualification pathways

You can qualify through any one of these.

Initial Authorization — MASH with moderate to advanced fibrosis

All of:

Age within range recommended by FDA label (adults)
Diagnosis of noncirrhotic MASH (formerly NASH) with moderate to advanced liver fibrosis consistent with stages F2 to F3, confirmed by clinical presentation along with laboratory findings and/or imaging and/or biopsy results
Patient does NOT have decompensated cirrhosis
Prescribed by or in consultation with a gastroenterologist or hepatologist
Prescriber attests Wegovy will be used in conjunction with diet and exercise and without excessive alcohol consumption
Prescribed dosage does not exceed Wegovy 2.4 mg subcutaneously once weekly

Re-Authorization — Continuation of MASH therapy

All of:

Patient continues to meet initial authorization requirements
Documentation of positive clinical response to therapy (e.g., improvement or stabilization of fibrosis)
Patient is maintained on Wegovy 2.4 mg or 1.7 mg weekly

Documentation to bring

Completed Universal PA Form
Supporting clinical documentation confirming MASH diagnosis with F2–F3 fibrosis (laboratory findings and/or imaging and/or biopsy results)
Documentation confirming absence of decompensated cirrhosis
Confirmation that prescription is by or in consultation with a gastroenterologist or hepatologist
Prescriber attestation that Wegovy will be used with diet and exercise and without excessive alcohol consumption
For re-authorization: documentation of positive clinical response (improvement or stabilization of fibrosis)

Quantity limits

0.25mg, 0.5mg, 1mg, 1.7mg, 2.4mg

Approval and renewal

Initial approval: 12 months
Renewal: every 12 months
To renew, the plan looks for Documentation of positive clinical response to therapy (e.g., improvement or stabilization of fibrosis) required. Patient must continue to meet initial authorization requirements and be maintained on Wegovy 2.4 mg or 1.7 mg weekly and staying on a maintenance dose of at least 1.7 mg.

Not covered when

Decompensated cirrhosis

Policy note: Policy is specific to Mississippi Division of Medicaid. Indication is noncirrhotic MASH with moderate to advanced fibrosis (F2–F3) in adults only. Maintenance dose target is 2.4 mg weekly; 1.7 mg is acceptable if 2.4 mg cannot be tolerated. The document does not specify lookback periods for biopsy or imaging, nor explicit alcohol gram limits — only a prescriber attestation of 'without excessive alcohol consumption' is required. No explicit quantity limits are stated in this document beyond the maximum dose of 2.4 mg subcutaneously once weekly.

Policy effective October 30, 2025 · verified June 4, 2026 · source: Wegovy-in-MASH-PA-Criteria-10-30-2025-to-Current.V1.pdf

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