# Does MaineCare Cover Wegovy or Zepbound? Heart, Liver and Sleep Apnea Rules

By Nora Bissett, Pricing Editor (https://glpwatchdog.org/authors/nora-bissett) | Published: 2026-11-07

Canonical page: https://glpwatchdog.org/research/maine-medicaid-glp1-coverage

> MaineCare still refuses GLP-1s for weight loss alone, and a 2025 bill to change that died in committee. Its October 2026 drug list makes Wegovy a preferred drug for heart risk and MASH on Form 23976, and pays for Zepbound only when sleep apnea persists despite CPAP.

## Key points

- MaineCare excludes weight-loss drugs outright, including phentermine and Xenical.
- Wegovy is a preferred drug with clinical review for heart risk or MASH, at a BMI over 27, on Form 23976.
- First Wegovy approvals last three months, and the MASH route is for the injection only, under a gut, liver or hormone specialist.
- Zepbound for sleep apnea needs a sleep study from the last three years, CPAP that failed, three months of lifestyle change and no diabetes.
- LD 480, the 2025 bill to cover obesity drugs, died in committee after a cost estimate above $42 million a year.

No. As of November 2026, MaineCare, Maine’s Medicaid program, does not cover Wegovy, Zepbound or any other drug for weight loss alone; its drug list says weight-loss drugs “are not covered.”[1] It does pay for Wegovy with prior authorization to cut heart risk or treat the liver disease MASH in adults with a BMI over 27, and for Zepbound in adults with sleep apnea once CPAP has failed or could not be tolerated.[1][2]

> **About this article.** This page reads the MaineCare preferred drug list effective October 1, 2026 (amended October 9), the Wegovy request form #23976 revised March 2026, and the legislature’s record on the 2025 coverage bill, as they stood on November 7, 2026. Maine’s rules website refused our requests, so the appeal deadline below is the federal limit rather than Maine’s own text. To compare states, use the [state Medicaid GLP-1 checker](https://glpwatchdog.org/tools/state-medicaid-glp1-checker).

## Will MaineCare pay for a GLP-1 to lose weight?

It will not. The weight-loss row of the drug list names phentermine and Xenical as no longer covered and says weight-loss drugs are excluded under federal Medicaid rules and MaineCare policy.[1] The Wegovy form repeats the point with a yes-or-no question asking whether the drug is for weight loss only.[2] Under federal law, states may leave these drugs out, and Maine does.[6] Our explainer on [how Medicaid splits diabetes and weight-loss GLP-1s](https://glpwatchdog.org/research/does-medicaid-cover-ozempic-and-wegovy) covers the federal side.

MaineCare also stopped covering orlistat and phentermine, so there is no older weight-loss drug to fall back on through the program.[1]

## Has Maine tried to add weight-loss coverage?

Yes, and it failed. LD 480, a 2025 bill to make MaineCare pay for GLP-1s approved for obesity, was voted out of committee as ought not to pass on March 20, 2025.[4] At the hearing, the MaineCare medical director testified that after rebates the benefit would cost more than $42 million in state fiscal 2026 and $53 million in 2027, with $14.5 million and $18.4 million of that from the state’s general fund.[5] The same testimony said MaineCare already covers GLP-1s for diabetes and would follow federal law in covering newly approved uses such as sleep apnea, which is the pattern the current drug list follows.[5][1] We found no later bill that changed the rule as of November 2026.

## When does MaineCare cover Wegovy?

For two uses beyond weight. On the October 2026 list, Wegovy sits in a class called cardiometabolic health agents, where the injection and the tablet are preferred drugs that still need clinical prior authorization.[1] The prescriber uses Form #23976, and a first approval lasts three months.[2]

*MaineCare Wegovy criteria, from the October 2026 drug list and Form #23976 (revised March 2026)*

| Use | Who qualifies | What to attach |
| --- | --- | --- |
| Lowering heart attack and stroke risk | An adult with a BMI over 27 and a past stroke, heart attack or symptomatic peripheral artery disease | Chart notes showing the heart history; the form also asks about a cholesterol-lowering drug and a current A1C |
| MASH with F2 to F3 liver fibrosis (injection only) | An adult with a BMI over 27, no decompensated cirrhosis, prescribed by or with a gastroenterologist, liver specialist or endocrinologist | Two noninvasive tests (blood and imaging) or a biopsy confirming the stage |
| Weight loss alone | Not covered | None |

Three details trip up requests. The BMI must be over 27, so a reading of exactly 27 does not qualify.[1] The MASH route is for the injection only, which matches the label: Wegovy tablets are not approved for MASH.[2][9] And the heart route asks for chart notes, not just a diagnosis code.[2] The form asks whether the patient has diabetes and which drugs they have tried, but neither the form nor the drug list bars people with diabetes from the heart or liver routes.[1][2] Our page on [GLP-1s for fatty liver disease and MASH](https://glpwatchdog.org/research/glp1-and-fatty-liver-mash) explains the trial behind the liver approval.

## Does MaineCare cover Zepbound for sleep apnea?

Yes, under criteria stricter than the drug’s label. Zepbound is listed under its own sleep apnea heading and is requested on the general form, #20420.[1] Every one of these must be true:[1]

- The patient is 18 or older, with a BMI from 30 up.
- A sleep study in the last three years shows moderate to severe sleep apnea, scored at 15 or more on the apnea-hypopnea index (AHI).
- CPAP has not worked, meaning the AHI stayed above 5 on the treatment part of the study, or the patient could not tolerate CPAP for at least 90 days.
- At least three months of diet and activity changes failed to bring weight down.
- There is no diabetes of either type on record.

The CPAP and lifestyle steps go beyond the label, which approves Zepbound for moderate to severe sleep apnea in adults with obesity without asking for a CPAP failure first.[8] A sleep study older than three years means a new one before filing. People with diabetes are steered to the diabetes drugs instead.[1] Our guide to [tirzepatide for sleep apnea](https://glpwatchdog.org/research/zepbound-for-sleep-apnea) covers the trials behind the approval.

## Does MaineCare cover Ozempic and Mounjaro for diabetes?

Ozempic, yes, with prior authorization; Mounjaro does not appear on the list. The preferred diabetes GLP-1s on the October 2026 drug list are Rybelsus, Trulicity and Victoza, with no prior authorization marker.[1] Ozempic is non-preferred, sixth in the step order, and the list says preferred drugs must be tried and fail before a non-preferred one is approved, unless the form gives an accepted clinical reason.[1] We searched the list for Mounjaro and tirzepatide and found only the Zepbound sleep apnea row.[1] A prescriber who wants Mounjaro should call the prior authorization help desk before writing it.

## How do you file, and who do you call?

*MaineCare pharmacy contacts, from the drug list, Form #23976 and the mainecarepdl.org contact page*

| Purpose | Phone | Fax |
| --- | --- | --- |
| Prior authorization help desk (prescribers) | 1-888-445-0497 | 1-888-879-6938 |
| Member help desk | 1-866-796-2463 | None listed |
| Pharmacy hearings coordinator | 1-866-796-2463 | 207-287-8601 |

The form must be legible and complete or it is returned, and it takes one drug per form.[2] The help desk numbers come from the state’s pharmacy site.[3]

## How do you appeal a MaineCare denial?

Check the reason first. A denial for a sleep study more than three years old, a missing CPAP record or a BMI of exactly 27 is usually fixed by refiling with the right record.[1] A denial because the drug is for weight loss alone has no route to win, because MaineCare excludes that use.[1]

For a hearing, federal rules let a state set the deadline but cap it at 90 days from the date the notice is mailed.[7] Use the date on your notice, and call the pharmacy hearings coordinator if it is unclear.[3] Our walkthrough of [building a prior authorization or appeal file](https://glpwatchdog.org/research/glp1-prior-authorization-and-appeals) covers what to send, and the [Maine state page](https://glpwatchdog.org/states/maine) keeps the basics in one place.

## What can you do if MaineCare will not pay?

Cash is the main option, and Lilly’s savings card excludes anyone on Medicaid.[10] In the figures we track, Novo Nordisk’s self-pay price for most Wegovy pen doses is $349 a month, and Lilly’s self-pay Zepbound costs $299 at the starting dose, $399 at 5 mg and $449 at higher doses refilled on time.[10][11] Read each program’s terms on government coverage first. Our list of the [cheapest ways to buy a GLP-1 without insurance](https://glpwatchdog.org/research/cheapest-glp1-without-insurance) compares them.

## Frequently asked questions

### Does MaineCare cover Wegovy for weight loss?

No. MaineCare's drug list excludes weight-loss drugs. As of November 2026 it covers Wegovy with prior authorization only to lower heart risk after a stroke, heart attack or symptomatic artery disease, or to treat MASH with F2 to F3 fibrosis, in adults with a BMI over 27.

### Does MaineCare cover Zepbound?

Only for sleep apnea. An adult needs a BMI from 30 up, a sleep study from the last three years showing an AHI of 15 or more, CPAP that failed or could not be tolerated for 90 days, three months of failed lifestyle changes, and no diabetes.

### Does MaineCare cover Ozempic?

Yes, for diabetes, but it is non-preferred. Rybelsus, Trulicity and Victoza are the preferred GLP-1s, and a preferred drug normally has to be tried first unless the prescriber gives an accepted clinical reason.

### How long does a MaineCare Wegovy approval last?

The first approval is limited to three months, according to the state's Form 23976 revised in March 2026. The prescriber has to file again to continue.

### Did Maine pass a law to cover weight-loss drugs in MaineCare?

No. LD 480, a 2025 bill to cover GLP-1s for obesity, was reported ought not to pass on March 20, 2025, after the state health department estimated a cost of more than $42 million a year.

## References

1. Maine Department of Health and Human Services, Office of MaineCare Services MaineCare Preferred Drug List, effective October 1, 2026 (amended October 9, 2026). mainecarepdl.org. 2026. https://mainecarepdl.org/content/dam/ffs-medicare/me/pdl/pdl-100926.pdf
2. Maine Department of Health and Human Services MaineCare/MEDEL Prior Authorization Form #23976: Semaglutide, Treatment for MACE reduction/MASH (C:03.26). mainecarepdl.org. 2026. https://mainecarepdl.org/content/dam/ffs-medicare/me/semaglutide-mace-23976-01.pdf
3. MaineCare PDL Contact information: prior authorization, member and pharmacy hearings help desks. mainecarepdl.org. 2026. https://mainecarepdl.org/content/mainecarepdl/en/contact.html
4. Maine Legislature LD 480 (HP 309), 132nd Legislature: An Act to Support Healthy Weight by Providing MaineCare Coverage for Certain Weight Loss Medications, text and status. legislature.maine.gov. 2025. https://legislature.maine.gov/legis/bills/display_ps.asp?LD=480&snum=132
5. Maine Department of Health and Human Services Testimony in opposition to LD 480 before the Joint Standing Committee on Health and Human Services, March 4, 2025. legislature.maine.gov. 2025. https://legislature.maine.gov/legis/bills/getTestimonyDoc.asp?id=184978
6. United States Code 42 U.S.C. §1396r-8: Payment for covered outpatient drugs (Social Security Act §1927). Legal Information Institute, Cornell Law School. 2026. https://www.law.cornell.edu/uscode/text/42/1396r-8
7. Centers for Medicare & Medicaid Services 42 CFR 431.221: Request for hearing. eCFR. 2026. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-431/subpart-E/section-431.221
8. Eli Lilly and Company ZEPBOUND (tirzepatide) injection: prescribing information. DailyMed. 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=487cd7e7-434c-4925-99fa-aa80b1cc776b
9. Novo Nordisk WEGOVY (semaglutide) injection and tablets: prescribing information. DailyMed. 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=ee06186f-2aa3-4990-a760-757579d8f77b
10. Eli Lilly and Company Zepbound savings and self-pay options, with card terms. zepbound.lilly.com. 2026. https://zepbound.lilly.com/savings
11. Novo Nordisk Wegovy savings offer. novocare.com. 2026. https://www.novocare.com/obesity/products/wegovy/savings-offer.html

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Cite as: GLP Watchdog, Nora Bissett, "Does MaineCare Cover Wegovy or Zepbound? Heart, Liver and Sleep Apnea Rules", published 2026-11-07. https://glpwatchdog.org/research/maine-medicaid-glp1-coverage

Canonical HTML page: https://glpwatchdog.org/research/maine-medicaid-glp1-coverage

Medical disclaimer: Nothing here is medical advice. We report on this subject; we do not treat anyone. Whether to begin a medication, supplement, or treatment, whether to adjust it, and whether to stop are questions for a clinician licensed to answer them, who knows your history.