Oregon Medicaid coverage for Wegovy (Liver Disease

Medicaid

Covered with requirements

What you need to qualify

Age 18 and older
Diagnosis documented with a code
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

Qualification pathways

You can qualify through any one of these.

MASH — Liver Biopsy Confirmation

All of:

Patient is 18 years of age or older
Diagnosis of MASH confirmed by liver biopsy
Fibrosis stage 2 or 3 as shown by liver biopsy within the past 24 months
Medication ordered by, or in consultation with, a hepatologist or gastroenterologist

MASH — Non-Biopsy Clinical Confirmation

All of:

Patient is 18 years of age or older
Documentation that patient does NOT have ongoing or recent (within 2 years) significant alcohol use or chronic/active viral hepatitis (significant alcohol use defined as >21 drinks/week or >30 g/day in men; >14 drinks/week or >20 g/day in women)
Provider attestation or documentation that other causes of hepatic steatosis are not suspected or have been ruled out (e.g., Wilson's disease, lipodystrophy, abetalipoproteinemia, medications such as amiodarone, methotrexate, tamoxifen, corticosteroids)
Documentation that patient has, or is receiving drug treatment for, at least 3 of the 5 metabolic risk factors (overweight/obesity/increased waist circumference [BMI ≥25 kg/m2 or ethnicity-adjusted equivalent], hypertension, type 2 diabetes mellitus, hypertriglyceridemia, decreased HDL)
Fibrosis stage 2 or 3 as shown by appropriate diagnostic test within the past 24 months (biopsy, VCTE, MRE, or ELF)
Medication ordered by, or in consultation with, a hepatologist or gastroenterologist

Documentation to bring

ICD-10 diagnosis code for MASH
Patient age 18 years or older
Liver biopsy confirming MASH with fibrosis stage 2 or 3 (within past 24 months) OR all of: (1) documentation of absence of significant alcohol use (within 2 years) and no chronic/active viral hepatitis; (2) provider attestation ruling out other causes of hepatic steatosis; (3) documentation of at least 3 of 5 metabolic risk factors; (4) fibrosis staging test (VCTE, MRE, ELF, or biopsy) within past 24 months showing stage 2 or 3
Order or consultation note from a hepatologist or gastroenterologist

Approval and renewal

Initial approval: 6 months
Renewal: every 12 months
To renew, the plan looks for At renewal: provider must attest to patient adherence (or adherence apparent from claims history); patient must have had a complete metabolic panel, liver enzymes, or other appropriate biochemical or noninvasive imaging test within the past 12 months to assess disease progression (examples: FIB-4, ELF, VCTE, MRE); if semaglutide initiation was more than 3 years ago, noninvasive imaging (VCTE or MRE) or repeat liver biopsy must have been done within the past 3 years; patient must NOT have evidence of stage F4 fibrosis (cirrhosis) or worsened fibrosis stage since starting semaglutide; documentation of a risk/benefit assessment for ongoing treatment with semaglutide with possible resolution of metabolic comorbidities must be present. If adherence is not confirmed, approve once for 3 months. If monitoring tests are missing, approve once for 3 months. If imaging/biopsy update is missing (>3 years), approve once for 3 months. If risk/benefit assessment is missing, approve once for 3 months.

Not covered when

Fibrosis stage F4 (cirrhosis) — triggers denial at renewal
Worsening fibrosis stage since starting semaglutide — triggers denial at renewal
Active or recent (within 2 years) significant alcohol use
Chronic or active viral hepatitis

Policy note: Injection only for MASH indication. Alcohol limit defined as >30 g/day (>21 drinks/week) for men and >20 g/day (>14 drinks/week) for women. The 24-month lookback applies to all fibrosis staging methods listed (biopsy, VCTE, MRE, ELF). At renewal, if semaglutide was initiated more than 3 years ago, a repeat imaging or biopsy within the past 3 years is required. The MASH pathway bypasses the standard BMI and lifestyle program requirements (approval criteria flow goes directly to #14 for MASH). The document also notes liraglutide (Saxenda) is covered for MASH with stage 2 or 3 fibrosis in adults ≥18 years, but liraglutide is not in the in-scope list.

Policy effective March 1, 2026 · verified June 4, 2026 · source: Oregon%20Medicaid%20PA%20Criteria%20Guide%20-%20June%201%2C%202026.pdf

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