Medicaid
Covered with requirementsWhat you need to qualify
- Age 18 and older
- BMI of 25 or higher
- BMI of 23 or higher for patients of Asian descent
- 6 months of a documented diet and exercise program
- Confirmed MASH diagnosis by FIB-4, FibroScan_VCTE, liver_biopsy, MRE, ELF_test, and FibroSure, fibrosis stage F1 to F3
- Lab results confirming eligibility
Qualification pathways
You can qualify through any one of these.
NASH/MASH with F1–F3 fibrosis — Adult ≥ 18
All of:
- Diagnosis of noncirrhotic NASH or MASH
- Adult (18 years of age or over)
- Medical records required
- Stage F1, F2, or F3 fibrosis confirmed by BOTH: (1) FIB-4 score consistent with F1–F3 fibrosis adjusted for age, AND (2) at least one of: liver biopsy, VCTE/FibroScan, ELF score, MRE, or FibroSure
- Requested agent is Wegovy
- Being monitored for development of and/or treated for any comorbid conditions (e.g., CVD, diabetes, dyslipidemia, hypertension)
- No decompensated cirrhosis
- No moderate to severe hepatic impairment (Child-Pugh Class B or C)
- No other liver disease (e.g., Wilson's disease, hepatocellular carcinoma, hepatitis)
- Currently on and will continue lifestyle modification including structured nutrition and physical activity
- Will NOT use in combination with another GLP-1 receptor agonist
- No FDA-labeled contraindications
Plus any one of:
- Baseline BMI > 25 kg/m² prior to beginning therapy
- Baseline BMI > 23 kg/m² if beneficiary is of South Asian, Southeast Asian, or East Asian descent
Documentation to bring
- Medical records confirming diagnosis of noncirrhotic NASH or MASH
- FIB-4 score consistent with stage F1, F2, or F3 fibrosis (adjusted for age)
- At least one confirmatory test result: liver biopsy, VCTE/FibroScan, ELF score, MRE, or FibroSure
- Baseline BMI documentation (>25 kg/m², or >23 kg/m² for South/Southeast/East Asian descent)
- Documentation of alcohol consumption (female <20 g/day, male <30 g/day)
- Documentation of monitoring or treatment for comorbid conditions (CVD, diabetes, dyslipidemia, hypertension)
- Documentation confirming absence of decompensated cirrhosis, Child-Pugh B/C hepatic impairment, and other liver disease
Quantity limits
- titration doses — 2 mL per 28 days
- maintenance doses — 3 mL per 28 days
Approval and renewal
- Initial approval: 6 months
- Renewal: every 6 months
- To renew, the plan looks for Medical documentation that beneficiary has improved while on medication AND individual clinical goals set by provider are being met OR beneficiary is continuing to make adequate progress towards treatment goals. Continued lifestyle modification required. No combination with another GLP-1. No FDA-labeled contraindications. Provider must document review of medication list at each renewal for possible dose reductions or discontinuation of comorbid medications. Note: Covered indication went into effect October 1, 2025; prior PA approval through Medicaid required before renewal.
Not covered when
- Decompensated cirrhosis
- Moderate to severe hepatic impairment (Child-Pugh Class B or C)
- Any other liver disease (e.g., Wilson's disease, hepatocellular carcinoma, hepatitis)
- Concurrent use with another GLP-1 receptor agonist
- Medullary thyroid carcinoma history
- Multiple endocrine neoplasia syndrome type 2 (MEN2)
- Lactation
- Pregnancy
Policy note: Fibrosis staging requires BOTH a FIB-4 score AND at least one additional confirmatory test (liver biopsy, VCTE/FibroScan, ELF, MRE, or FibroSure). No explicit lookback periods are specified for these tests in the document. The Asian descent BMI threshold (>23 kg/m²) applies to South Asian, Southeast Asian, and East Asian patients. The document labels this indication as NASH or MASH (noncirrhotic). Covered indication went into effect October 1, 2025 per renewal section.
Policy effective August 1, 2024 · verified June 4, 2026 · source: download