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Coverage of Wegovy for MACE and MASH, and Zepbound for OSA
Act
by Sep 30, 2026
Effective date
Oct 1, 2026
Identified
Sep 11, 2026
Summary
Effective October 1, 2026, Illinois Medicaid (both FFS and Managed Care) will cover Wegovy (semaglutide tablets and injection) for MACE reduction in adults with established cardiovascular disease and obesity/overweight, and for MASH treatment with moderate-to-advanced liver fibrosis (F2-F3). Zepbound (tirzepatide) is now covered for moderate-to-severe obstructive sleep apnea in adults with obesity. All three indications require prior authorization. Weight loss alone remains non-covered.
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What to do
by Sep 30, 2026 · 6 steps
01Billing team must configure billing system to require prior authorization for all Wegovy and Zepbound claims.
02Update prior authorization submission templates to include: diagnosis code (MACE, MASH with F2-F3 fibrosis, or OSA), proof of established cardiovascular disease (for Wegovy MACE indication), liver fibrosis staging documentation (for Wegovy MASH indication), and recent clinical notes demonstrating medical necessity.
03Providers and APRNs must document qualifying diagnosis and medical necessity in clinical notes before prescribing.
04Front desk and clinical staff must educate patients that weight loss alone is not a covered indication.
05Route prior authorization requests to appropriate MCO or Department of Healthcare and Family Services (contact: 877-782-5565 for questions).
06Claims submitted without prior authorization or missing required documentation will be denied.
Original notice
Coverage of Wegovy for MACE and MASH, and Zepbound for OSA
hfs.illinois.gov · Always check the source before changing claims.