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Pennsylvania Medicaid · Liver Disease (MASH)

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

Medicaid

Covered with requirements

What you need to qualify

  • Prior trial of another GLP-1 medication (Ozempic)
  • Prescribed by or in consultation with a specialist
  • On guideline-directed medical therapy (optimized pharmacotherapy for established comorbid diseases (cardiovascular disease, dyslipidemia, diabetes, hypertension) per current consensus guidelines)
  • Confirmed MASH diagnosis by liver_biopsy, FIB-4, 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.

Initial approval — Wegovy for MASH (non-preferred)

All of:

  • Prescribed by or in consultation with a hepatologist or gastroenterologist
  • Diagnosis of MASH with moderate to advanced liver fibrosis (stage F2 or F3) confirmed by approved method
  • No significant alcohol use (defined as >1 drink/day for natal females or >2 drinks/day for natal males) and no alcohol dependence
  • Used in combination with optimized pharmacotherapy for established comorbid diseases (CVD, dyslipidemia, diabetes, hypertension) per current consensus guidelines unless contraindicated or not tolerated
  • Used in combination with lifestyle changes and behavioral modifications
  • Age-appropriate per FDA labeling, compendia, or peer-reviewed literature
  • No contraindication to the prescribed drug
  • History of therapeutic failure of, OR contraindication to, OR intolerance to the maximum FDA-approved dose of Ozempic (semaglutide)

Plus any one of:

  • Liver biopsy within the past 3 years confirming F2-F3 fibrosis
  • FIB-4 index >= 1.3 (age <65) or >= 2.0 (age >=65) PLUS one of: liver stiffness by VCTE (FibroScan), MRE, shear wave elastography (SWE), or Enhanced Liver Fibrosis (ELF) score

Initial approval — Wegovy 2.4 mg for MASH (non-preferred, strength-specific)

All of:

  • All standard MASH criteria above met

Plus any one of:

  • Dose titration to semaglutide 2 mg completed AND medical reason supporting need for 2.4 mg dose
  • History of therapeutic failure of Ozempic (semaglutide) at maximum FDA-approved dose

Initial approval — addition of Wegovy to Rezdiffra (resmetirom) for MASH

All of:

  • All standard MASH criteria above met
  • Failed to show improvement in liver fibrosis after >= 12 months of Rezdiffra (resmetirom)

Documentation to bring

  • Documentation of specialist prescribing or consultation (hepatologist or gastroenterologist)
  • Documentation of MASH diagnosis with F2-F3 fibrosis: liver biopsy within past 3 years OR FIB-4 >= 1.3 (<65 yrs) or >= 2.0 (>=65 yrs) plus VCTE/MRE/SWE/ELF result
  • Documentation of no significant alcohol use (<=1 drink/day natal female; <=2 drinks/day natal male) and no alcohol dependence
  • Documentation of optimized pharmacotherapy for comorbid diseases or reason contraindicated/not tolerated
  • Documentation of therapeutic failure of Ozempic at maximum FDA-approved dose, OR contraindication or intolerance to Ozempic (with chart documentation of troubleshooting attempts over at least 1 month if intolerance-based)
  • For Wegovy 2.4 mg: documentation that dose titration to semaglutide 2 mg has been completed and medical reason for 2.4 mg dose — OR therapeutic failure of Ozempic at max dose
  • If currently on Rezdiffra (resmetirom): documentation of failure to improve liver fibrosis after >= 12 months of Rezdiffra
  • Documentation of age-appropriateness per FDA labeling, compendia, or peer-reviewed literature
  • Documentation of no contraindication to the prescribed drug
  • If therapeutic duplication: documentation of intent to transition or medical reason for concomitant use

Approval and renewal

  • Initial approval: 6 months
  • Renewal: every 6 months
  • To renew, the plan looks for Renewal requires: (1) prescribed by or in consultation with hepatologist or gastroenterologist; (2) no significant alcohol use; (3) optimized pharmacotherapy for comorbid diseases; (4) continued lifestyle changes and behavioral modifications; (5) step-therapy requirement (therapeutic failure/contraindication/intolerance to Ozempic max dose). If on GLP-1 for >= 1 year, must document: resolution of steatohepatitis and improvement or no worsening of liver fibrosis, OR improvement of liver fibrosis and no worsening of steatohepatitis. If currently taking Rezdiffra (resmetirom) and adding GLP-1: must have failed to show improvement in liver fibrosis after >= 12 months of Rezdiffra. Baseline fibrosis staging not re-confirmed at renewal per renewal guidelines.

Not covered when

  • Cirrhotic MASH excluded (noncirrhotic MASH only)
  • Significant alcohol use (>1 drink/day natal female or >2 drinks/day natal male) or alcohol dependence is an exclusion
  • Overweight/obesity treatment indication excluded
  • Saxenda (liraglutide) not covered for any indication

Policy note: MASH fibrosis confirmation: liver biopsy must be within past 3 years (36 months). For FIB-4 pathway, FIB-4 cutoff is age-stratified: >=1.3 for patients <65 years old, >=2.0 for patients >=65 years old. Second-line imaging/test required alongside FIB-4: VCTE (FibroScan), MRE, SWE, or ELF score. Alcohol limits are stated in drinks per day, not grams (policy does not specify gram equivalents). Concomitant Rezdiffra requires prior 12-month trial failure of resmetirom before adding GLP-1. At renewal, if on GLP-1 for >=1 year, must document liver fibrosis/steatohepatitis response. All non-OSA/non-MASH/non-CV non-diabetes indications require 6-month prior lifestyle trial; MASH requires only concurrent lifestyle modification. Approval up to 6 months per cycle. Prescriptions limited to 1-month supply per fill.

Policy effective January 1, 2026 · verified June 4, 2026 · source: mab2025112403.pdf

All Wegovy policies under Pennsylvania Medicaid · Check your card