WEGOVY (semaglutide) — Prior Authorization Criteria for MASH (F2–F3)
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Prior authorization criteria for use of WEGOVY (semaglutide) to treat noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH) with moderate to advanced fibrosis (F2–F3) in adults under Mississippi Division of Medicaid.
No material clinical or coverage changes in this revision.
Coverage Criteria for WEGOVY (semaglutide) — MASH (F2–F3)
Initial Authorization
Covered when ALL of the following are met
- Age of the patient is within the age range as recommended by the FDA label.
- Patient has a diagnosis of metabolic dysfunction-associated steatohepatitis (MASH) with moderate to advanced liver fibrosis (F2–F3) confirmed by clinical presentation plus laboratory findings and/or imaging and/or biopsy results.
- Patient does NOT have decompensated cirrhosis.
- Prescribed by or in consultation with a gastroenterologist or hepatologist.
- Prescriber attests WEGOVY will be used in conjunction with diet and exercise and without excessive alcohol consumption.
- Prescribed dosage does NOT exceed WEGOVY 2.4 mg subcutaneously once weekly.
Re-Authorization
Re-authorization covered when ALL of the following are met
- Patient continues to meet initial authorization requirements.
- Documentation of positive clinical response to therapy (e.g., improvement or stabilization of fibrosis).
- Patient is maintained on either Wegovy 2.4 mg or 1.7 mg weekly.
Patients with decompensated cirrhosis are excluded from coverage under these criteria. This exclusion is explicit in the initial authorization requirements and will result in denial of prior authorization if present.
Dosage and Coding Details
Provider Requirements and Authorization Workflow
Prior authorization required; approval only when all criteria met
Prior authorization is required for WEGOVY (semaglutide). Approval will be considered only when all initial authorization criteria are met, including age within the FDA label range, confirmed diagnosis of MASH with F2–F3 fibrosis, absence of decompensated cirrhosis, prescriber is a gastroenterologist or hepatologist (or in consultation with one), attestation that therapy will be used with diet and exercise and without excessive alcohol consumption, and prescribed dose does not exceed 2.4 mg subcutaneously once weekly. Submit the Universal PA Form with supporting documentation as instructed.
- Age within FDA label range is required
- Diagnosis of MASH (F2–F3) must be confirmed by clinical presentation with laboratory findings and/or imaging and/or biopsy
- Patient must NOT have decompensated cirrhosis
- Prescribed by or in consultation with a gastroenterologist or hepatologist
- Prescriber must attest use with diet and exercise and without excessive alcohol consumption
- Dose must not exceed 2.4 mg subcutaneously once weekly
No step therapy required
No step therapy requirements are specified in this policy for WEGOVY use in MASH.
Submit Universal PA Form and supporting clinical documentation
Submit the Universal PA Form along with supporting clinical documentation that confirms the diagnosis of MASH with moderate to advanced fibrosis (F2–F3) — confirmation may include clinical presentation plus laboratory findings and/or imaging and/or biopsy — and documentation that the prescriber will use WEGOVY with diet and exercise and without excessive alcohol consumption, plus dosing information.
- Universal PA Form must be included
- Clinical confirmation of MASH with F2–F3 using labs, imaging, and/or biopsy
- Attestation that therapy is used with diet and exercise and without excessive alcohol consumption
- Document prescribed dose (must not exceed 2.4 mg once weekly)
Triggers for denial: decompensated cirrhosis, excessive dose, prescriber specialty
Prior authorization may be denied if the patient has decompensated cirrhosis, the prescribed dose exceeds WEGOVY 2.4 mg once weekly, or the prescriber is not a gastroenterologist/hepatologist or is not acting in consultation with one.
- Presence of decompensated cirrhosis excludes coverage
- Doses above 2.4 mg subcutaneously once weekly exceed the covered maximum
- Prescriber must be a gastroenterologist or hepatologist, or the request must show consultation with one
Clinical Background
WEGOVY (semaglutide) is a glucagon-like peptide-1 (GLP-1) receptor agonist used as a once-weekly subcutaneous therapy. In this policy the agent is addressed specifically for treatment of noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH) with moderate to advanced liver fibrosis (stages F2–F3) in adults. The prior authorization criteria require that use follow the FDA age recommendations, be prescribed by or in consultation with a gastroenterologist or hepatologist, be used in conjunction with diet and exercise and without excessive alcohol consumption, and that the prescribed dose not exceed 2.4 mg once weekly.
Definitions and Maintenance Dosage
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