Medicaid
Covered with requirementsWhat you need to qualify
- A1C no higher than 10%
- Trial of metformin for at least 90 days, or a documented reason it can't be used (["intolerance", "hypersensitivity", "contraindication"])
- Prior trial of another GLP-1 medication (Trulicity, Victoza, and liraglutide) for at least 90 days
- Lab results confirming eligibility
Qualification pathways
You can qualify through any one of these.
Pathway 1: T2DM without cardiovascular/renal comorbidities
All of:
- Diagnosis of T2DM
- Baseline labs (A1C within 3-6 months, A1C goal, eGFR/CrCL/Albumin)
- Current HgbA1C above goal
- A1C <= 10%
- Requested medication is age-appropriate per Table 1
- Ineffective treatment response to preferred injectable GLP1-RAs (Trulicity AND [Victoza OR liraglutide]) at optimized dose for at least 3 months OR documented intolerance/hypersensitivity/contraindication to preferred injectable GLP1-RAs
Plus any one of:
- Ineffective treatment response to metformin at optimized dose for at least 3 months
- Documented intolerance/hypersensitivity/contraindication to metformin
Pathway 2: T2DM with concurrent ASCVD or high risk of ASCVD
All of:
- Diagnosis of T2DM
- Baseline labs (A1C within 3-6 months, TC, LDL)
- A1C <= 10%
- Requested medication has demonstrated cardiovascular benefits per Table 1
- Requested medication is age-appropriate per Table 1
- Ineffective treatment response to preferred injectable GLP1-RAs (Trulicity AND [Victoza OR liraglutide]) at optimized dose for at least 3 months OR documented intolerance/hypersensitivity/contraindication to preferred injectable GLP1-RAs
Plus any one of:
- Concurrent atherosclerotic cardiovascular disease (ASCVD)
- High risk of ASCVD
Pathway 3: T2DM with concurrent CKD
All of:
- Diagnosis of T2DM
- Concurrent chronic kidney disease (CKD)
- Baseline labs (A1C, GFR/CrCL/albuminuria)
- A1C <= 10%
- Requested medication has demonstrated CKD benefits per Table 1
- Requested medication is age-appropriate per Table 1
- Ineffective treatment response to preferred injectable GLP1-RAs (Trulicity AND [Victoza OR liraglutide]) at optimized dose for at least 3 months OR documented intolerance/hypersensitivity/contraindication to preferred injectable GLP1-RAs
Plus any one of:
- Ineffective treatment response to metformin AND SGLT2-i (Invokana, Farxiga, or Jardiance) at optimized dose for at least 3 months
- Documented intolerance/hypersensitivity/contraindication to metformin and/or SGLT2i
Pathway 4: T2DM with concurrent HFpEF and obesity
All of:
- Diagnosis of T2DM
- Concurrent symptomatic heart failure with preserved ejection fraction (HFpEF)
- Obesity
- Baseline labs (LVEF >= 50%, BMI/weight/height, A1C)
- A1C <= 10%
- Requested medication has demonstrated reduction of HF-related symptoms
- Requested medication is age-appropriate per Table 1
Plus any one of:
- Ineffective treatment response (HF-related symptom reduction) to two different preferred SGLT2-is (Invokana, Farxiga, or Jardiance) at optimized dose for at least 3 months
- Documented intolerance/hypersensitivity/contraindication to SGLT2-i
Pathway 5: T2DM with concurrent MASLD/MASH
All of:
- Diagnosis of T2DM
- Concurrent MASLD or MASH
- Biopsy-proven MASH
- Baseline labs (LFTs, FIB-4, BMI)
- A1C <= 10%
- Requested medication is age-appropriate per Table 1
Plus any one of:
- Ineffective treatment response to pioglitazone at optimized dose for at least 3 months AND ineffective treatment response to preferred GLP1-RA (liraglutide) at optimized dose for at least 3 months
- Documented intolerance/hypersensitivity/contraindication to pioglitazone AND documented intolerance/hypersensitivity/contraindication to preferred GLP1-RA (liraglutide)
Documentation to bring
- Baseline A1C lab result within 3-6 months
- Documentation that current HgbA1C is above goal
- Documentation that requested medication is age-appropriate (per Table 1)
- Documentation of metformin trial at optimized dose for at least 3 months with inadequate response, OR documented intolerance/hypersensitivity/contraindication to metformin
- Documentation of ineffective treatment response to preferred injectable GLP1-RAs (Trulicity AND [Victoza OR liraglutide]) at optimized dose for at least 3 months, OR documented intolerance/hypersensitivity/contraindication to preferred injectable GLP1-RAs (for non-preferred agent)
- For ASCVD pathway: Baseline lipid labs (TC, LDL); documentation of concurrent ASCVD or high ASCVD risk; documentation that Mounjaro has demonstrated CV benefits
- For CKD pathway: Baseline GFR/CrCL/albuminuria labs; documentation of CKD; documentation that Mounjaro has demonstrated CKD benefits; documentation of SGLT2i trial/failure or contraindication
- For HFpEF pathway: LVEF >= 50% documentation; BMI/weight/height; documentation of HFpEF and obesity; documentation of SGLT2i trial/failure x2 or contraindication
- For MASH pathway: LFTs, FIB-4, BMI; biopsy-proven MASH; documentation of pioglitazone trial/failure or contraindication; documentation of liraglutide trial/failure or contraindication
Approval and renewal
- Initial approval: 6 months
- Renewal: every 12 months
- To renew, the plan looks for History of compliance and documented positive response to medication.
Not covered when
- Concurrent use of DPP4-I, other GLP1-RA (oral or injectable), or GLP1/GIP
- History of pancreatitis
- Personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia type 2A/2B
- HgbA1C > 10% in individuals with T2DM
- Liver cirrhosis (for MASH diagnosis pathway)
- Medication requested for obesity alone or in combination with another condition secondary to obesity (IL Medicaid policy)
- Pregnancy
- Type 1 diabetes
Policy note: Non-preferred agent on Illinois Medicaid PDL. Preferred agents are Trulicity (dulaglutide), Victoza (liraglutide), and liraglutide (generic) — all Step 4. Mounjaro requires step therapy through preferred injectable GLP1-RAs. Step therapy requires trial of BOTH Trulicity AND (Victoza OR liraglutide) unless intolerance/contraindication documented. Obesity alone or secondary to another condition is explicitly excluded per IL Medicaid policy. Initial approval is 30-day supplies for 6 months; renewal is 30-day supplies for 12 months. Table 1 referenced for age-appropriateness and cardiovascular/CKD benefit verification but not reproduced in this document. Note: Mounjaro's cardiovascular and CKD benefits per Table 1 are referenced but not confirmed in document text; reviewer should verify Table 1 includes Mounjaro for these pathways.
Policy effective April 29, 2025 · verified June 4, 2026 · source: policy-359.html