Skip to content
myglp1coverage.com

Wisconsin Medicaid · Liver Disease (MASH)

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

Medicaid

Covered with requirements

What you need to qualify

  • Age 18 and older
  • Prescribed by or in consultation with a specialist
  • Confirmed MASH diagnosis by liver_biopsy, FibroScan_VCTE, and MRE, fibrosis stage F2 to F3

Qualification pathways

You can qualify through any one of these.

MASH — Noncirrhotic MASH with moderate to advanced fibrosis

All of:

  • Wegovy prescribed consistent with FDA-approved labeling
  • Diagnosis of noncirrhotic MASH (formerly NASH) with moderate to advanced liver fibrosis consistent with stages F2 to F3
  • Fibrosis confirmed by biopsy or noninvasive tests (FibroScan MRE + MRI-PDFF)
  • Member will use medication in conjunction with diet and exercise
  • Prescriber documents no significant alcohol consumption within the past year
  • Prescription written by a liver specialist physician (gastroenterologist or hepatologist)
  • Prescriber will monitor for elevations in liver tests and development of liver-related adverse reactions

Documentation to bring

  • Completed, signed, and dated PA/DGA form Section VI
  • Completed PA/RF
  • Supporting clinical information and copy of member's current medical records
  • Documentation of member's medical condition (noncirrhotic MASH with F2-F3 fibrosis)
  • Biopsy results or noninvasive test results (FibroScan MRE + MRI-PDFF) confirming F2-F3 fibrosis
  • Documentation of no significant alcohol consumption within the past year
  • Documentation of prescriber identity as liver specialist (gastroenterologist or hepatologist)
  • Details regarding previous medication use
  • Member's current treatment plan

Approval and renewal

  • Initial approval: 6 months
  • Renewal: every 6 months
  • To renew, the plan looks for Initial renewal (up to 183 days): documentation that member is responding adequately to treatment as documented in laboratory tests; appropriate maintenance dose per Wegovy PI; adherence required. Subsequent renewals (up to 365 days): documentation of adequate treatment response via laboratory tests AND biopsy or noninvasive tests (FibroScan or MRE + MRI-PDFF) showing either resolution of steatohepatitis without worsening of fibrosis OR at least one stage improvement in fibrosis without worsening of steatohepatitis; appropriate maintenance dose; adherence required.

Not covered when

  • Cirrhotic MASH is excluded — only noncirrhotic MASH qualifies
  • Significant alcohol consumption within the past year is a disqualifier
  • Must be adherent with prescribed treatment regimen for renewal
  • Subsequent renewal requires documented histologic or imaging response
  • Cannot be submitted via DAPO Center or STAT-PA system — portal, fax, or mail only

Policy note: ForwardHealth (Wisconsin Medicaid). Separate PA pathway and submission form (PA/DGA Section VI) from general anti-obesity criteria. Requires prescription by a gastroenterologist or hepatologist. Noninvasive test confirmation described as 'FibroScan MRE (magnetic resonance enterography) + MRI-PDFF (proton density fat fraction)' — this appears to refer to FibroScan and/or MRE with MRI-PDFF. Subsequent renewals require objective evidence of treatment response (histologic or imaging). No BMI threshold is stated for the MASH indication specifically. Fibrosis staging F2-F3 (noncirrhotic).

verified June 3, 2026 · source: Pa policy

All Wegovy policies under Wisconsin Medicaid · Check your card