Washington Medicaid coverage for Wegovy (Liver

Medicaid

Covered with requirements

What you need to qualify

Age 18 and older
A1C no higher than 6.5%
Confirmed MASH diagnosis by liver_biopsy, FIB-4, FibroScan_VCTE, APRI, Fibrotest, and Elastography_ARFI_PSWE, fibrosis stage F2 to F3
Lab results confirming eligibility
Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

Initial approval: Moderate to severe noncirrhotic MASH (F2-F3) without diabetes

All of:

Age >= 18 years
No diabetes and A1C <= 6.5% (patients with T2DM or A1C >6.5 referred to GLP-1 diabetes policy 27.17.00)
Diagnosis of moderate to severe MASH (fibrosis stage F2 or F3) confirmed by at least one listed method
At least one cardiovascular risk factor from Appendix A (CKD, dyslipidemia, hypertension, obesity BMI >=30, or prediabetes)

Plus any one of:

Liver biopsy confirming F2-F3 fibrosis
FIB-4 score 1.3 to 3.48
FibroScan score 8.5 to 13.5 kPa
APRI score 1.0 to 1.9
Fibrotest score 0.49 to 0.74
Elastography (ARFI/PSWE) 1.38 to 2.33 m/s

Reauthorization: MASH

All of:

Member has received previous authorization approval OR has been established on therapy from another health plan (excludes samples, patient assistance programs, or coupons)
Patient continues to meet initial criteria 1-4 (age, no T2DM/A1C >6.5%, MASH F2-F3 confirmation, CV risk factor)
Patient does not have cirrhosis (fibrosis score must not be >F3)

Documentation to bring

Documentation confirming no diabetes diagnosis and A1C <= 6.5%
Diagnosis of moderate to severe noncirrhotic MASH (F2 or F3) confirmed by one of: liver biopsy, FIB-4 score 1.3-3.48, FibroScan 8.5-13.5 kPa, APRI 1.0-1.9, Fibrotest 0.49-0.74, or Elastography (ARFI/PSWE) 1.38-2.33 m/s
Documentation of at least one cardiovascular risk factor (CKD, dyslipidemia, hypertension, obesity BMI >=30, or prediabetes)

Quantity limits

0.25 mg/0.5 mL, 0.5 mg/0.5 mL, 1 mg/0.5 mL, 1.7 mg/0.75 mL — 4 pens per 28 days (1 box of 4 pens) — Initial PA
2.4 mg/0.75 mL — 4 pens per 28 days (1 box of 4 pens) — Renewal PA

Approval and renewal

Initial approval: 6 months
Renewal: every 12 months
To renew, the plan looks for Patient must continue to meet initial criteria 1-4 (age >=18, no T2DM/A1C >6.5%, MASH F2-F3 diagnosis confirmed, at least one cardiovascular risk factor) AND patient must not have cirrhosis (fibrosis score must not be >F3). Noncirrhotic status re-verified at reauthorization.

Not covered when

Patients with T2DM or A1C > 6.5% are excluded (referred to GLP-1 diabetes policy 27.17.00)
Cirrhosis (fibrosis stage >F3) is an exclusion at reauthorization
Only injectable formulation (not tablet) covered for MASH indication

Policy note: MASH indication covers only Wegovy injection, not the Wegovy tablet. The policy title spells 'nonalchoholic' (sic). Fibrosis staging is limited to noncirrhotic disease (F2-F3); cirrhosis (>F3) is an explicit exclusion at reauthorization. Cardiovascular risk factors from Appendix A are listed as 'including but not limited to': CKD, dyslipidemia, hypertension, obesity (BMI >=30), and prediabetes. No lookback periods are specified for any confirmation method. Specific score ranges are provided for each non-biopsy confirmation method mapping to F2-F3 disease.

Policy effective February 1, 2026 · verified June 4, 2026 · source: semaglutide.pdf

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