Medicaid
Covered (preferred drug)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 FibroScan_VCTE, FIB-4, MRE, and liver_biopsy, fibrosis stage F2 to F3
Qualification pathways
You can qualify through any one of these.
Initial approval for NASH/MASH
All of:
- Patient is 18 years of age or older
- Diagnosis of NASH or MASH
- Fibrosis stage F2 or F3 confirmed by an approved diagnostic method
- Prescriber attests patient is participating in a supervised comprehensive weight management program
- Prescribed by or in consultation with a gastroenterologist or hepatologist
- Will not be used concomitantly with DPP-4 inhibitors
- Will not be co-administered with another GLP-1 receptor agonist
- No personal or immediate family history of medullary thyroid carcinoma or MEN2
Plus any one of:
- Fibrosis confirmed by FibroScan
- Fibrosis confirmed by Fibrosis-4 index (FIB-4)
- Fibrosis confirmed by Magnetic Resonance Elastography (MRE)
- Fibrosis confirmed by liver biopsy
Documentation to bring
- Medical records (e.g., chart notes) confirming diagnosis of NASH or MASH
- Medical records confirming fibrosis stage F2 or F3 via FibroScan, FIB-4, MRE, or liver biopsy
- Prescriber attestation that patient is participating in a supervised comprehensive weight management program
- Documentation of prescriber specialty (gastroenterologist or hepatologist) or consultation note
- Documentation that patient has no personal or immediate family history of medullary thyroid carcinoma or MEN2
Quantity limits
- 0.25mg, 0.5mg, 1mg, 1.7mg, 2.4mg — 4 injectors
Approval and renewal
- To renew, the plan looks for Positive clinical response required: improvement in NASH/MASH disease symptoms documented in recent medical records (chart notes and/or labs).
Not covered when
- Personal or immediate family history of medullary thyroid carcinoma or MEN2
- Concomitant use of DPP-4 inhibitors
- Co-administration with another GLP-1 receptor agonist
Policy note: Document uses both NASH and MASH terminology interchangeably. Fibrosis stage must be F2 or F3 (not F1, F4, or cirrhotic). No specific lookback periods stated for diagnostic tests. Specialist requirement: prescribed by or in consultation with a gastroenterologist or hepatologist. Renewal only requires positive clinical response documentation; specialist, BMI, and fibrosis confirmation requirements are not explicitly re-verified at renewal.
Policy effective June 1, 2026 · verified June 3, 2026 · source: Criteria-PDL.pdf