New Hampshire Medicaid coverage for Wegovy (Liver Disease (MASH))

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, FibroScan_VCTE, MRE, and ELF_test, fibrosis stage F2 to F3
• Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Documentation of MASH (previously NASH) diagnosis
• Confirmation of prescriber is or has consulted a gastroenterologist or hepatologist
• Liver biopsy report within past 2 years (if using biopsy route): confirming steatosis, NAS >= 4, score >= 1 in each NAS component, and fibrosis stage 1–3
• FibroScan (VCTE) results showing >= 8.5 kPa and CAP >= 280 dB/m (if using FibroScan route)
• MRE results showing >= 2 and < 4 kPa (if using MRE route)
• PRO-C3 lab result > 14 ng/mL OR ELF score >= 9 (if using biochemical route)
• MRI-PDFF result showing >= 8% liver fat
• Documentation of current statin use and intent to continue, OR documentation of intolerance/hypersensitivity/contraindication to all statins
• Documentation of lifestyle modifications implemented (diet, exercise)
• Attestation of no significant alcohol consumption (>3 consecutive months) in the past 12 months
• Attestation of no hepatocellular carcinoma, no other liver disease, MELD score < 12 (unless due to therapeutic anticoagulation)
• Attestation of no bariatric surgery within the past year

Approval and renewal

• Initial approval: 12 months
• Renewal: every 12 months
• To renew, the plan looks for Patient must continue to meet all initial approval criteria AND demonstrate disease improvement evidenced by NASH resolution or improvement in liver fibrosis AND must not have experienced treatment-restricting adverse effects (e.g., hepatotoxicity, gallbladder-related adverse reactions, statin-related adverse reactions when given concurrently with a statin).

Not covered when

• History of significant alcohol consumption for more than 3 consecutive months within previous 12 months
• Hepatocellular carcinoma (HCC)
• Any other liver disease (e.g., Wilson's disease, hepatitis)
• MELD score >= 12 unless due to therapeutic anticoagulation
• Cirrhotic NASH (only noncirrhotic F2–F3 fibrosis is covered)
• Bariatric surgery

Policy note: This is a New Hampshire Medicaid Fee-for-Service policy administered by Prime Therapeutics State Government Solutions LLC. The policy applies to both Wegovy (semaglutide) and Rezdiffra (resmetirom) under the same shared MASH criteria, with criteria items 9 and 10 being Rezdiffra-only (CYP2C8 inhibitor exclusion and OATP1B1/1B3 inhibitor exclusion). Wegovy is not subject to those two exclusions. The liver biopsy fibrosis staging note specifies 'stage 1, 2, or 3' are acceptable under the biopsy route, even though the overall indication targets F2–F3; the biopsy route's minimum fibrosis_stage_min reflects the F2 policy intent per the indication description. The document does not specify quantity limits for Wegovy. The statin requirement is effectively a GDMT-type requirement specific to MASH management. Renewal requires continued adherence to all initial criteria plus documented disease improvement and absence of treatment-restricting adverse effects.

Policy effective October 1, 2025 · verified June 4, 2026 · source: 4a490bb0-6ec4-9e4c-09a5-2c257b186da2