Applies to Medicaid plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
MASH with F2 or F3 fibrosis — Wegovy only
All of:
- Wegovy (non-preferred) — medical necessity for non-preferred use documented
- Participant is aged ≥ 18 years
- Recent liver biopsy or noninvasive techniques confirming MASH with F2 or F3 fibrosis
- Documented current liver function tests (LFTs)
- Prescribed by or in consultation with a gastroenterologist, hepatologist, or other specialist in the treated disease state
- Lack of diabetes mellitus diagnosis in the past 2 years
- Recent A1C < 6.5 within the past 3 months confirming absence of diabetes diagnosis
- Lack of any history of anti-diabetic pharmaceutical therapy in the past 2 years
Documentation to bring
- Documentation of medical necessity for using Wegovy instead of preferred agent (Zepbound)
- Participant age documentation (≥ 18 years)
- Recent liver biopsy or noninvasive techniques confirming MASH diagnosis with F2 or F3 fibrosis
- Documented current liver function tests (LFTs)
- Prescription from or documentation of consultation with a gastroenterologist, hepatologist, or other specialist in the treated disease state
- Documentation confirming no diabetes mellitus diagnosis in the past 2 years
- Recent A1C < 6.5 within the past 3 months
- Documentation confirming no anti-diabetic pharmaceutical therapy in the past 2 years
Quantity limits
- 0.25 mg/0.5 mL pen, 0.5 mg/0.5 mL pen, 1 mg/0.5 mL pen — 2 mL per 28 days
- 1.7 mg/0.75 mL pen, 2.4 mg/0.75 mL pen — 3 mL per 28 days
Approval and renewal
- Renewal: Staying on a maintenance dose of at least 1.7 mg.
Not covered when
- Concurrent therapy with another GLP-1 receptor agonist
- Unable to complete titration/dose escalation to at least 1.7 mg/dose within 6 months of beginning therapy
- Cirrhotic MASH (policy states 'noncirrhotic' MASH)
- Diabetes mellitus diagnosis within past 2 years
- Any history of anti-diabetic pharmaceutical therapy in past 2 years
- A1C ≥ 6.5 on recent lab
Policy note: This is a Wegovy-specific MASH pathway. The policy specifies 'noncirrhotic' MASH. The MASH confirmation methods are described as 'recent liver biopsy or noninvasive techniques' — specific noninvasive methods (e.g., FIB-4, FibroScan, MRE, ELF) are not enumerated. No explicit lookback period stated for biopsy or noninvasive tests ('recent' used without definition). Titration rules same as other Wegovy indications. The diabetes exclusion criteria (no DM diagnosis in past 2 years, no anti-diabetic therapy in past 2 years, A1C < 6.5 within 3 months) apply to all Wegovy-specific pathways per the document structure. Specialist requirement: prescribed by or in consultation with a gastroenterologist, hepatologist, or other specialist.
Policy effective January 29, 2026 · verified June 3, 2026 · source: Policy 311 · View policy document (PDF)