Maryland Medicaid GLP-1 Coverage (2026): Pattern #17 — Regulatory-Exclusion + Dual-Indication Carve-Out (Wegovy ASCVD + MASH via HCPCS J3490 Medical-Benefit Pathway) + Active "Authorization" Legislation in Conference Committee (COMAR 10.09.03.05(A)(14) + PT 35-25 + MDH Pharmacy News & Views Nov 2025 + SB 0496/HB 0813 2026 RS)

TL;DR

Maryland Medicaid — the Maryland Medical Assistance Program, administered by the Maryland Department of Health (MDH) through the mandatory managed-care HealthChoice program and a fee-for-service (FFS) track — does not cover GLP-1 receptor agonists for the chronic-weight-management FDA indication. The exclusion is anchored at three levels: (1) COMAR 10.09.03.05(A)(14) — “Oral drugs or injections for central nervous system stimulants, anorexigenics, and any other agents when used for weight control”; (2) 42 U.S.C. § 1396r-8(d)(2)(A) — the federal optional-exclusion authority for agents used for anorexia, weight loss, or weight gain; and (3) PT 35-25 (September 13, 2024), which states verbatim: “Wegovy will not be covered when the sole indication is for chronic weight management for patients that are either obese (BMI 30) or overweight (BMI 27) with comorbidities.”

Maryland Medicaid does cover Wegovy — with prior authorization — for two specific non-weight-loss FDA-approved indications: (1) established ASCVD (atherosclerotic cardiovascular disease) to reduce MACE risk (effective September 15, 2024); and (2) noncirrhotic moderate-to-severe (F2/F3) MASH (metabolic dysfunction-associated steatohepatitis) (added 11/30/2025). Critically, both carve-outs are reimbursed via HCPCS code J3490 priced per invoice — a medical-benefit billing pathway — not through the retail-pharmacy PDL. Wegovy does not appear on Advisory 282 (the FFS PDL, effective January 1, 2026) because it is not a retail-pharmacy benefit in Maryland Medicaid. Zepbound and Saxenda are not covered for any indication.

The 2026 Maryland General Assembly passed SB 0496 / HB 0813 — an “Authorization” bill (not a coverage mandate) — through both chambers, but the bill entered conference committee on 4/09/2026 to resolve House-Senate amendment differences before the General Assembly’s April 2026 adjournment. Even if enacted, the bill authorizes MDH to provide obesity-treatment coverage beginning January 1, 2027, contingent on a CMS State Plan Amendment. Coverage is not guaranteed. Maryland is Pattern #17 in this 50-state series and is the first state in the cluster with an enabling-statute (“Authorization”) bill rather than a coverage mandate in conference committee.

Per-state taxonomy positioning: Pattern #17 in the 50-state series

Maryland is the 17th state documented in this 50-state Medicaid GLP-1 series (after TX, CA, NY, FL, OH, IL, PA, GA, MI, NC, NJ, AZ, TN, WA, MA, IN) and occupies a distinctive position in the taxonomy for five reasons:

1. Dual-indication carve-out (MACE + MASH): Maryland covers Wegovy for both MACE-risk reduction and MASH fibrosis — one of the broader non-weight-loss indication portfolios in the series. Structurally comparable to Washington (WA #14) and New Jersey (NJ #11) on the Wegovy side, but Maryland does NOT cover Zepbound for OSA — a distinctive narrowing.
2. HCPCS J3490 medical-benefit pathway: Maryland reimburses Wegovy ASCVD/MASH through physician-administered medical billing, not the retail-pharmacy PDL. Most analogous states (WA, NJ, OH) reimburse non-weight-loss Wegovy via the retail-pharmacy / PBM channel with PA. Maryland’s medical-benefit architecture means Advisory 282 correctly omits Wegovy — Wegovy is not a pharmacy benefit.
3. High-Cost Low-Volume risk corridor: Wegovy ASCVD/MASH costs are removed from MCO capitation rate-setting. All nine HealthChoice MCOs invoice MDH quarterly, producing mechanically uniform coverage across the managed-care program without MCO formulary discretion.
4. “Authorization” enabling-statute bill in conference committee: SB 0496 / HB 0813 (2026) has passed both chambers (Senate 43-0 and 41-0; House 110-26) and entered conference committee 4/09/2026 — the furthest-advanced obesity-coverage legislation in the 17-state series. But it is an “Authorization” (permissive enabling statute) not a mandate — a material legal distinction.
5. KFF not-covering classification: Maryland is not among KFF’s 13 covering states (January 2026). KFF and MDH both classify Wegovy ASCVD/MASH coverage as non-obesity coverage, consistent with the indication anchor.

COMAR 10.09.03.05(A)(14) — the Maryland regulatory weight-control exclusion

The canonical Maryland state-regulation anchor for the GLP-1 weight-management exclusion is COMAR 10.09.03.05(A)(14), verified via Cornell LII and cross-confirmed at mdrules.elaws.us. The verbatim provision states:

“Oral drugs or injections for central nervous system stimulants, anorexigenics, and any other agents when used for weight control.”

COMAR 10.09.03.05 lists the non-covered items in the Maryland Medicaid pharmacy program. Subsection (A)(14) covers appetite-suppressant agents (“anorexigenics”) and, through the catch-all language “any other agents when used for weight control,” extends to Wegovy, Zepbound, Saxenda, Foundayo, Qsymia, Contrave, and any other agent prescribed for the chronic-weight-management indication — regardless of molecular class, formulation, or mechanism. Maryland last amended COMAR 10.09.03.05 effective March 31, 2025; the (A)(14) language has remained unchanged, as confirmed by MDH’s own November 2025 Pharmacy News & Views publication.

The federal floor that all state Medicaid programs may invoke is 42 U.S.C. § 1396r-8(d)(2)(A), which authorizes (but does not require) state Medicaid programs to exclude:

“Agents when used for anorexia, weight loss, or weight gain.”

Maryland affirmatively elects this federal exclusion through COMAR 10.09.03.05(A)(14). The December 2024 MDH Joint Chairman’s Report (JCR) notes:

“Section 1927(d)(2) of the Act allows states to exclude certain drugs including ‘agents when used for anorexia, weight loss, or weight gain’ from Medicaid coverage. In turn, Part D, Medicare’s outpatient drug benefit, does not cover drugs or classes of drugs, or their medical uses, which are excluded from coverage or otherwise restricted under section 1927(d)(2) of the Act.”

MDH Pharmacy News & Views (November 2025) — the cleanest primary-source YMYL anchor in the 17-state series

MDH’s Office of Pharmacy Services publishes the Pharmacy News & Views newsletter on mmppi.com (the Acentra Health-operated Maryland Medicaid Pharmacy Program portal). The Fall 2025 issue, published November 2025, is the most-recent MDH public-facing summary of GLP-1 coverage policy. It contains what this series has identified as the cleanest, most-recently-attested verbatim weight-loss exclusion statement found across all 17 state primary-source sweeps:

“In accordance with COMAR 10.09.03.05 (A)(14), prescriptions for weight control indications will not be covered at this time. For reference, see Clinical Criteria.”

This sentence does several things simultaneously: it names the binding regulation by full citation; it uses the phrase “will not be covered at this time,” which acknowledges the active, present-tense operational status of the exclusion while leaving open a future policy change; and it was published by the official MDH pharmacy services office in its own newsletter — not by an MCO, not by a PBM, not in a contractor document. It is MDH speaking directly in its official communication channel. The source is stable and retrievable at its original URL.

The same issue places the exclusion in clinical context with its “Glucagon-like Peptide 1 Receptor Agonists (GLP-1 RA) Review” section, which notes:

“Recently several GLP-1 RAs that were originally approved for weight loss received FDA approval for new indications. In March 2024, Wegovy (semaglutide) was approved in combination with a reduced calorie diet and increased physical activity to reduce the risk of major adverse cardiovascular events (MACE: cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) in adults with established cardiovascular disease and either obesity or overweight. Then in August 2025, Wegovy received accelerated approval for noncirrhotic MASH, with moderate to advanced liver fibrosis (consistent with stages F2 to F3 fibrosis) in adults, making it the first GLP-1 receptor agonist approved for this indication.”

This paragraph establishes the clinical logic for the two Maryland Medicaid carve-outs: both follow the FDA indication rather than the weight-management pathway. A member whose prescriber is pursuing Wegovy for ASCVD or MASH is not seeking a weight-loss drug — the FDA indication is for a separate approved use. The COMAR exclusion is indication-specific: it bars weight-control prescribing, not Wegovy categorically.

The November 2025 newsletter also confirms contact channels for members and providers:

“Conduent Technical Assistance: 800-932-3918, 24 hours a day, 7 days a week. Maryland Medicaid Pharmacy Access Hotline: 833-325-0105, Monday–Friday, 8:00 am – 5:00 pm.”

Conduent operates the Maryland Medicaid pharmacy POS / claims-adjudication / Help Desk infrastructure (per Advisory 282). Acentra Health operates the mmppi.com PDL portal. For FFS pharmacy questions, the Conduent 24-hour line (800-932-3918) is the primary provider contact.

HCPCS J3490 medical-benefit pathway: why Wegovy ASCVD/MASH is not at retail pharmacy

This is the single most operationally important distinction for prescribers and members: Wegovy’s coverage in Maryland Medicaid does not run through the retail-pharmacy Preferred Drug List.

PT 35-25 (September 13, 2024) states verbatim:

“The Medicaid FFS program will reimburse Wegovy under HCPCS code J3490 and will be priced per invoice. Billable units are defined as 1 ml. For information about clinical criteria and reimbursement by HealthChoice MCOs, please contact the MCOs directly.”

HCPCS J3490 is an unclassified injection code, used when a drug does not have its own specific HCPCS J-code. Billing under J3490 “per invoice” means MDH reimburses the actual invoice price of the drug, not a fixed fee schedule rate. This is the standard billing mechanism for physician-administered drugs — infusion agents, biologic injectables, and other drugs dispensed and administered in a clinical setting — rather than drugs a member fills at a retail pharmacy and self-administer at home.

The practical consequences for members, prescribers, and pharmacies are:

1. Advisory 282 correctly omits Wegovy. The FFS Preferred Drug List covers retail-pharmacy-dispensed drugs. Wegovy is not on the PDL because it is not a retail-pharmacy benefit in Maryland Medicaid. A member who calls Conduent or their MCO and reports that “Wegovy is not on the formulary” is correct at the PDL level — but incorrect about coverage overall.
2. Billing goes through professional services / medical claims, not pharmacy POS. FFS claims for Wegovy ASCVD/MASH are submitted through MDH Professional Services (mdh.professionalservicespolicy@maryland.gov), not through the Conduent pharmacy POS. This is the same pathway a prescriber uses to bill for an office-administered injectable.
3. Members cannot fill Wegovy at a retail pharmacy under their Maryland Medicaid coverage. The dispensing and administration occur in physician offices, hospital outpatient departments, or other outpatient clinical settings. Retail pharmacies cannot submit a J3490 claim through the pharmacy POS for Medicaid reimbursement.
4. HealthChoice MCO members follow the same J3490 pathway under the High-Cost Low-Volume risk corridor. MCOs invoice MDH quarterly (see the risk-corridor section below). Members on HealthChoice managed care should contact their MCO for the specific PA submission process — PT 35-25 directs: “For HealthChoice related questions, please contact mdh.healthchoiceprovider@maryland.gov.”

The December 2024 JCR confirms this non-PDL architecture when it describes the current-coverage status:

“The Medical Assistance Program covers Byetta, Ozempic, Trulicity, Victoza, Bydureon, Mounjaro, Rybelsus, and Wegovy for FDA-approved indications other than obesity. Byetta, Ozempic, Trulicity, Victoza, Bydureon, Mounjaro, and Rybelsus are all covered when used to treat type 2 diabetes.”

Note the asymmetry: the seven T2DM drugs are covered “when used to treat type 2 diabetes” and appear in the PDL’s Hypoglycemics-Incretin Mimetics class. Wegovy is listed separately — covered for “FDA-approved indications other than obesity” but not through the same pharmacy-PDL mechanism.

The dual-indication carve-out: verbatim PA criteria for Wegovy ASCVD and Wegovy MASH

Wegovy for ASCVD (MACE-risk reduction)

PT 35-25 established the ASCVD pathway effective September 15, 2024. The verbatim coverage criteria:

“Effective September 15, 2024, Wegovy will be considered for FFS coverage when the patient:
• Is 18 years of age or older;
• Has established and documented atherosclerotic cardiovascular disease (ASCVD);
• Is overweight or obese;
• Does not have type 1 or type 2 diabetes; and
• Is prescribed in accordance with prescribing information.
All of the preauthorization criteria must be met and confirmed with supporting medical documentation. MCOs must also cover Wegovy in accordance with the FFS preauthorization criteria.”

The November 30, 2025 update to the MDH Preauthorization Criteria added a cardiologist consultation requirement — tightening the 2024 criteria. The current verbatim ASCVD initial-approval criteria:

“ASCVD:
• Patient is 18 years of age or older
• Prescribed by or in consultation with a cardiologist
• The patient has established and documented atherosclerotic cardiovascular disease (ASCVD) and is either obese or overweight.
◦ Obesity/Overweight is defined as: For patient ≥ 27 kg/m² — Documentation of BMI ≥ 27 kg/m² within the last 90 days (current height and weight)
◦ ASCVD is defined as one or more of the following: Prior myocardial infarction; Prior stroke (ischemic or hemorrhagic stroke); OR Symptomatic peripheral arterial disease (PAD) as evidenced by: intermittent claudication with ABI less than 0.85 (at rest); peripheral arterial revascularization procedure; OR amputation due to atherosclerotic disease.
• Prescriber attests that medication is prescribed in accordance with prescribing information, including screening for any black box warnings and all contraindications.”

PT 35-25 explains the clinical rationale:

“On March 8, 2024, the U.S. Food and Drug Administration (FDA) approved a new indication for Wegovy for overweight and obese adults with cardiovascular disease. FDA labeling for Wegovy now indicates that, in combination with a reduced calorie diet and increased physical activity, Wegovy can help limit risk for additional major adverse cardiovascular events in adults who are obese or overweight. Wegovy contains semaglutide, a glucagon-like peptide-1 (GLP-1) receptor agonist, and should not be used in combination with other semaglutide-containing products or other GLP-1 receptor agonists.”

Wegovy for MASH (noncirrhotic F2/F3 fibrosis) — added 11/30/2025

The MASH carve-out is 5.5 months old at the time of this article’s publication. The verbatim MDH MASH criteria:

“MASH:
• The patient is 18 years of age or older.
• Prescribed by or in consultation with a gastroenterologist or hepatologist
• The patient has noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH), with moderate to advanced liver fibrosis (consistent with stages F2 to F3 fibrosis).
◦ Diagnosis of noncirrhotic MASH with liver fibrosis stage F2 or F3, confirmed by liver biopsy or one of the non-invasive testing methods listed in the Appendix within the last 180 days.
• Absence of concurrent use of another medication(s) indicated for noncirrhotic MASH.
• Prescriber attests that medication is prescribed in accordance with prescribing information, including screening for any black box warnings and all contraindications.
• Patients will be excluded from treatment when: There are documented causes of chronic liver disease other than non-alcoholic fatty liver disease (NAFLD); Presence of liver cirrhosis or a history of decompensated liver diseases; History of liver transplantation or current/prior hepatocellular carcinoma; Excessive alcohol consumption (20 gm per day for female; 30 gm per day for male).”

The MDH policy appends a noninvasive testing table specifying which scores qualify a patient as having F2-F3 fibrosis without biopsy:

* CPT code not available for FNI and MACK-3; per MDH criteria, scores may be submitted to fulfill the diagnostic requirement.

Authorization length: initial 4 months for both indications; continuation 6 months. Per the policy:

“Wegovy will be authorized for four months when the criteria for initial approval are met. Continuing therapy with Wegovy will be authorized for an additional six months.”

High-Cost Low-Volume risk corridor: how MCO coverage of Wegovy ASCVD/MASH works

The nine HealthChoice MCOs are not free to independently exclude or restrict Wegovy ASCVD/MASH coverage — PT 35-25 mandates alignment with FFS preauthorization criteria: “MCOs must also cover Wegovy in accordance with the FFS preauthorization criteria.” The mechanism that makes this operationally workable is the High-Cost Low-Volume (HCLV) risk-mitigation policy, described verbatim in the December 2024 JCR:

“High-cost low volume drug risk mitigation policy: Implemented effective January 1, 2021, this policy is designed to protect the HealthChoice program from utilization fluctuations related to very high-cost drugs. The policy covers both Physician Administered Drugs and retail pharmacy drugs that had an expected annual cost of over $400,000 for CYs 2021 to 2023. This threshold was changed to $500,000 for CY 2024.

Under this mitigation policy, costs of the High-Cost Low Volume drugs are removed from the rate-setting base data and are not included in the standard capitation rate paid to HealthChoice MCOs. The MCOs are still responsible for authorizing, managing, and paying all claims related to the high-cost drugs, and invoice MDH for any incurred expenses on a quarterly basis. The MCOs are expected to develop and adhere to medical necessity criteria to ensure that all instances of utilization of drugs subject to the policy follow best clinical practices. MDH reserves the right to audit medical necessity criteria and review the utilization of all High-Cost Low Volume Drugs to ensure adherence to appropriate criteria.”

In plain terms: Wegovy ASCVD/MASH costs are taken off the MCO capitation payment. The MCO pays the claim when a qualifying member uses Wegovy for ASCVD or MASH, then invoices MDH quarterly for the incurred cost. Because the cost does not flow through capitation, MCOs have no financial incentive to restrict access below the MDH clinical criteria — the cost is reimbursed by MDH regardless of which MCO is involved. This produces mechanically uniform coverage across all nine HealthChoice MCOs without any MCO formulary-deferral language.

The JCR also notes that the HCLV framework was designed before any Medicaid AOM expansion. If the SB 0496 / HB 0813 authorization is enacted, MDH would face a materially different scale and would need to design a new risk-corridor structure. The JCR states:

“MDH has some pre-existing mitigation strategies for managing the costs of certain drugs, including a risk corridor for high-cost low volume drugs, the hepatitis C risk pool, and a mitigation policy for moderate cost high volume drugs. If coverage is expanded to include anti-obesity drugs, substantial participant demand and need is expected to drive a significant fiscal impact to MDH, and by extension, the MCOs. MDH anticipates it would implement a risk corridor based mitigation strategy in the HealthChoice Program as a result. The structure of the risk corridor is yet to be determined.”

SB 0496 / HB 0813 (2026): the “Authorization” bill — not a mandate, not enacted as of last verification

The 2026 Maryland General Assembly bill is titled verbatim: “Maryland Medical Assistance Program – Coverage for the Treatment of Obesity – Authorization.” The synopsis: “Authorizes Maryland Medical Assistance Program coverage for obesity treatment beginning January 1, 2027, with department notification requirements and CMS State plan amendment authority.”

The bill has passed both chambers with substantial margins:

As of the last-verified date on this article, the conference committee outcome has not been verified. The Maryland General Assembly’s Sine Die was approximately April 13, 2026. Readers publishing or acting on this information after that date must verify: (a) whether the conference committee reached agreement; (b) whether the enrolled bill was transmitted to Governor Wes Moore; and (c) whether the Governor signed or vetoed the bill. Final status is available at mgaleg.maryland.gov for both SB 496 and HB 813 under the 2026 Regular Session.

The “Authorization” vs. “Mandate” distinction is legally meaningful. An enabling statute authorizes MDH to provide coverage — it gives MDH the legal power to do so, which MDH currently lacks for the chronic-weight-management indication. A coverage mandate would require MDH to provide coverage. The 2026 bill is the former. Even if enacted and signed, the bill requires MDH to:

1. Apply for a CMS State Plan Amendment (SPA) — federal approval is required before any new Medicaid benefit can be offered.
2. Notify Medicaid recipients of coverage as specified in the bill.
3. Build administrative infrastructure — PA criteria, formulary additions, PDL updates, MCO contract amendments, PBM integration.

At a minimum, coverage under this bill would not begin before January 1, 2027, and could be later if CMS SPA processing takes longer than anticipated. This article does not predict the timeline.

The failed 2025 mandate model: SB 876 / HB 1489 — why “Coverage” became “Authorization”

The 2025 predecessor bills — SB 876 (Senators Hershey and Mautz) and HB 1489 (Delegates Martinez, Alston, and Turner) — were coverage mandates, not enabling statutes. The SB 876 Fiscal Note summarizes:

“This bill requires Medicaid, beginning July 1, 2026, to provide ‘comprehensive coverage for the treatment of obesity,’ including coverage for intensive behavioral therapy, bariatric surgery, and any medication approved by the U.S. Food and Drug Administration (FDA) with an indication for chronic weight management in patients with obesity.”

The 2025 fiscal note projected:

“Medicaid expenditures increase by an estimated $225.8 million (58.9% federal funds, 41.1% general funds) in FY 2027 to cover anti-obesity medications, including staff and contractual modifications. Federal fund revenues increase accordingly. Future years reflect inflation. This bill increases the cost of an entitlement program beginning in FY 2027.”

SB 876 did not advance from Senate Finance Committee. HB 1489 did not advance from House Health and Government Operations Committee. Both bills died in the 2025 session without a floor vote. The December 2024 JCR (which the legislature commissioned in 2024 to estimate the cost of AOM expansion) projected a net cost of $225M–$437.7M for a full obesity-coverage expansion — a range that evidently persuaded the legislature that a straightforward mandate was not yet affordable. The architectural shift from “Coverage” (2025) to “Authorization” (2026) reflects a legislative-craft recognition that the permissive pathway was more likely to pass.

T2D coverage is separate: what Maryland Medicaid covers for diabetes-indication GLP-1s

Maryland Medicaid covers seven GLP-1 receptor agonists and combination products for the type-2-diabetes-mellitus indication through the Hypoglycemics, Incretin Mimetics and Enhancers class on Advisory 282 (January 1, 2026). The coverage map:

A critical point for members with T2DM: Ozempic (semaglutide for T2DM) is a Preferred drug on Advisory 282, while Wegovy (semaglutide for ASCVD/MASH) is not on the PDL at all. These are the same molecule — semaglutide — in different FDA-approved doses and formulations, reimbursed through entirely different benefit pathways. Ozempic coverage cannot be transitioned to Wegovy coverage by switching indications on a pharmacy claim.

PBM and administrative architecture: Conduent, Acentra Health, MDH Office of Pharmacy Services, and the P&T Committee

Maryland Medicaid’s pharmaceutical administration involves four distinct entities:

1. Conduent — operates the Medicaid FFS pharmacy point-of-sale (POS) and claims-adjudication infrastructure. Per Advisory 282: “contact Conduent’s 24-hour Help Desk at 800-932-3918.” Conduent processes retail-pharmacy FFS claims against the PDL. Because Wegovy ASCVD/MASH is a medical-benefit drug (J3490), it does not flow through Conduent’s pharmacy POS.
2. Acentra Health — operates the mmppi.com public-facing PDL portal and publishes the Pharmacy News & Views newsletter. Providers and members can find the current PDL, clinical criteria, and policy updates at mmppi.com.
3. MDH Office of Pharmacy Services (OPS) — the state agency authority. OPS sets the PDL, issues advisories, publishes clinical criteria, and issues pharmacy transmittals (including PT 35-25). Professional Services at mdh.professionalservicespolicy@maryland.gov is the contact for FFS questions about J3490 medical-benefit claims for Wegovy ASCVD/MASH.
4. MDH Pharmacy and Therapeutics (P&T) Committee — external physicians, pharmacists, and consumer representatives who meet quarterly to recommend Preferred/Non-Preferred drug status. Final determinations are made by MDH OPS. The PDL updates semi-annually (January and July). The July 2026 PDL update is the next scheduled revision; verify whether any GLP-1 or anti-obesity drug class changes are included.

The nine HealthChoice MCOs: uniform Wegovy ASCVD/MASH coverage, no MCO formulary deferrals

HealthChoice enrolls approximately 1.4 million of Maryland’s 1.6 million Medicaid beneficiaries. The nine MCOs as of contract year 2026 are: Aetna Better Health of Maryland, AmeriHealth Caritas Maryland, CareFirst BlueCross BlueShield Community Health Plan, Jai Medical Systems Managed Care Organization, Kaiser Permanente of the Mid-Atlantic States (Kaiser Foundation Health Plan of the Mid-Atlantic), Maryland Physicians Care, MedStar Family Choice, Priority Partners (Johns Hopkins HealthCare), and UnitedHealthcare Community Plan of Maryland.

PT 35-25 mandates uniform MCO alignment: “MCOs must also cover Wegovy in accordance with the FFS preauthorization criteria.” The High-Cost Low-Volume risk corridor (MCOs invoice MDH quarterly) eliminates any MCO financial incentive to restrict access below MDH criteria. The JCR confirms the structure:

“The MCOs are still responsible for authorizing, managing, and paying all claims related to the high-cost drugs, and invoice MDH for any incurred expenses on a quarterly basis. The MCOs are expected to develop and adhere to medical necessity criteria to ensure that all instances of utilization of drugs subject to the policy follow best clinical practices.”

For T2DM GLP-1s, all HealthChoice MCOs are contractually required to align with the MDH FFS PDL (Hypoglycemics-Incretin Mimetics class). Ozempic, Trulicity, Byetta, and Victoza remain Preferred across the MCO program. MCO-specific prior-authorization details for Wegovy ASCVD/MASH claims should be confirmed directly with the individual MCO — HealthChoice provider line: mdh.healthchoiceprovider@maryland.gov.

How Maryland compares to the 16 prior states in the series

Maryland’s most meaningful comparators in the series are Washington (WA, #14), New Jersey (NJ, #11), and Ohio (OH, #6) — all three are indication-anchored states with COMAR-parallel weight-loss exclusion regulations and non-obesity carve-outs. The key differences:

• vs. WA (#14): Both have explicit weight-loss regulatory exclusions and MACE + MASH carve-outs. Washington also covers Zepbound for OSA; Maryland does not. Washington reimburses through retail pharmacy (Covered/PA on the AHPDL); Maryland uses the J3490 medical-benefit pathway. WA’s pending legislation (SB 5353 / HB 1326) is a mandate still in committee; MD’s legislation is an “Authorization” in conference committee — farther along legislatively. KFF classifies WA as “covering”; KFF does not classify MD as covering — because MD’s coverage attaches only to non-obesity FDA indications.
• vs. NJ (#11): Both have administrative-code weight-loss exclusions (COMAR 10.09.03.05(A)(14) and N.J.A.C. 10:51-1.13(a)(2)) and Wegovy MACE + MASH carve-outs. NJ also covers Zepbound OSA; MD does not. NJ reimburses through retail pharmacy with PA; MD via J3490 medical benefit. NJ A3369 is a coverage mandate in committee; MD’s bill is an Authorization in conference committee. Both have published dollar-quantified fiscal projections (NJ: $208.3M; MD JCR: $225M–$437.7M).
• vs. OH (#6): OH’s January 2026 P&T-approved Metabolic Modifiers class is structurally similar to Maryland’s carve-outs; MD reached the Wegovy MACE pathway 16 months earlier (September 2024 vs. January 2026). Neither state covers Zepbound OSA. OH reimburses through the SPBM retail-pharmacy pathway; MD via J3490.
• vs. IL (#5), TX (#1), FL (#4), GA (#8), AZ (#12), IN (#16): All are explicit non-coverage states with no Wegovy ASCVD or MASH carve-outs. Maryland is operationally broader — it has had an active coverage pathway since September 2024.
• vs. NY (#3): NY’s Wegovy MACE pathway has a stricter BMI threshold (BMI ≥ 40) and a lifetime two-attempt cap; MD uses BMI ≥ 27 and no lifetime cap. MD additionally covers Wegovy MASH; NY does not as of this article.

Who is excluded: the full scope of Maryland Medicaid GLP-1 non-coverage

Beyond the weight-management indication, the following populations and drugs are explicitly outside Maryland Medicaid coverage as of the last-verified date:

• Wegovy for chronic weight management (BMI ≥ 30, or BMI ≥ 27 with comorbidities, without a qualifying ASCVD or MASH diagnosis): excluded by COMAR 10.09.03.05(A)(14) and PT 35-25 verbatim. This is the primary exclusion affecting most members who want Wegovy for obesity.
• Zepbound (tirzepatide) for any indication, including the FDA-approved obstructive sleep apnea indication: not on Advisory 282 (January 1, 2026 PDL) for any indication, and the weight-management indication is excluded by COMAR.
• Saxenda (liraglutide for weight management): not on Advisory 282 for any indication. Excluded by COMAR.
• Foundayo (orforglipron, Lilly’s oral GLP-1, November 2025): not on the January 1, 2026 PDL. Cash-pay through LillyDirect is the only access pathway as of the last-verified date. Outside the Medicaid claims pathway.
• Phentermine, benzphetamine, diethylpropion, phendimetrazine, Qsymia, Contrave, Xenical, orlistat, Alli: all absent from Advisory 282. All fall under COMAR 10.09.03.05(A)(14).
• Compounded semaglutide and compounded tirzepatide: not a Maryland Medicaid benefit. Compounded preparations are not FDA-approved products and do not have HCPCS codes that map to Maryland Medicaid coverage.
• Wegovy for ASCVD in patients with type 1 or type 2 diabetes: the PT 35-25 and MDH criteria require the absence of T1D or T2D as a condition of ASCVD coverage. A member with both T2DM and ASCVD cannot use the ASCVD carve-out.

Patient action steps and the Maryland Office of Administrative Hearings appeal pathway

For a Maryland Medicaid member who wants Wegovy for obesity without a qualifying ASCVD or MASH diagnosis, the realistic pathways are limited and do not include a straightforward coverage appeal:

1. Confirm ASCVD or MASH diagnosis: work with a cardiologist (for ASCVD) or gastroenterologist/hepatologist (for MASH) to determine whether you meet the MDH criteria. For MASH, confirm fibrosis stage via biopsy or one of the noninvasive tests listed in the MDH appendix. If you qualify, request PA through your MCO or FFS prescriber for Wegovy under the HCPCS J3490 medical-benefit pathway.
2. T2DM pathway: if you have type-2 diabetes, discuss with your prescriber whether Ozempic (semaglutide, Preferred on Advisory 282 for T2DM) or Mounjaro (tirzepatide, Non-Preferred, PA required for T2DM) are clinically appropriate for your T2DM management. T2DM coverage does not require obesity criteria.
3. If denied, request your MCO’s internal appeal: for HealthChoice members, file an internal appeal within the deadline on the denial letter. Expedited appeals (when medically urgent) must be resolved within 72 hours.
4. State Fair Hearing through the Maryland Office of Administrative Hearings (OAH): if the MCO internal appeal is denied or not resolved in your favor, request a State Fair Hearing. You must request within 90 days from the NOA date. The ALJ issues a written decision within 30 days. The OAH final decision is appealable to Maryland Circuit Court. Contact OAH at oah.maryland.gov.
5. Maryland Office of the Attorney General HEAU: the Health Education and Advocacy Unit (410-528-1840 / toll-free 877-261-8807 / MarylandCares.org) can provide free guidance on Medicaid appeals. Disability Rights Maryland also provides Medicaid fair-hearing self-help resources.

An important limitation on appeals: for weight-management-only denials under COMAR 10.09.03.05(A)(14), a State Fair Hearing can correct adjudication errors (for example, if MDH misread your diagnosis code or incorrectly applied the criteria), but cannot overturn the underlying regulation. Where the regulation itself excludes the prescription, the ALJ cannot create coverage that the regulation prohibits. The most impactful recourse for weight-management-only exclusions is legislative — tracking SB 0496 / HB 0813 and any future MDH OPS policy update.

Related research

• Washington Apple Health (Medicaid) GLP-1 coverage 2026: YMYL trap — indication-anchored with verbatim weight-loss exclusion — the closest structural analog to Maryland in the series. Both states have explicit COMAR/WAC weight-loss exclusions AND active MACE + MASH carve-outs for Wegovy. Key differences: WA additionally covers Zepbound for OSA (MD does not); WA reimburses through retail pharmacy PDL (MD uses HCPCS J3490 medical benefit); WA’s pending legislation is a mandate still in committee while MD’s authorization bill reached conference committee before Sine Die.
• Illinois Medicaid GLP-1 coverage 2026: explicit regulatory exclusion (89 IAC § 140.441(b)) — another regulatory-exclusion state, but with zero indication-anchored carve-outs. The comparison illustrates why Maryland’s Pattern #17 is meaningfully more permissive than Pattern #5 (IL): both anchor on a state administrative code and the federal 42 U.S.C. § 1396r-8(d)(2)(A) authority, but Illinois has published no MACE, MASH, or OSA pathway. Maryland is the dual-carve-out state within the regulatory-exclusion cluster.
• GLP-1 pricing index: compounded and brand-name cost benchmarks — relevant for Maryland members who are excluded from the Medicaid weight-management pathway and evaluating cash-pay compounded or brand alternatives. Maryland’s HCPCS J3490 medical-benefit pathway for Wegovy ASCVD/MASH is one of the most atypical reimbursement structures in the 17-state series — and a reminder that even where Medicaid “covers” a drug, the billing pathway shapes who can practically access it.
• GLP-1 insurance appeal playbook: what to do when your coverage is denied or dropped — for Maryland Medicaid members navigating the MCO internal appeal and OAH State Fair Hearing process described in this article.

Sources and last-verified date

Last verified: 2026-05-10. All primary sources were retrieved and verified by direct curl + pdftotext extraction or direct URL fetch on this date. Key revision triggers: (1) July 2026 MDH PDL semi-annual update — monitor for any GLP-1 or anti-obesity drug class additions; (2) SB 0496 / HB 0813 conference committee outcome and gubernatorial signature/veto — check mgaleg.maryland.gov; (3) any new MDH Preauthorization Criteria update for Wegovy (last reviewed 11/30/2025); (4) next MDH Pharmacy News & Views publication; (5) CMS SPA filing and approval status if SB 0496 / HB 0813 is enacted.

This article was compiled using primary-source documents only — no AI-synthesized clinical data. All verbatim quotations are from verified PDFs or verified webpage text. Sources are listed in the citations section below.