Maryland Medicaid and GLP-1 coverage

The exclusion is a regulation and it is broad. COMAR 10.09.03.05A provides that except as specifically identified as covered, the following are not covered, and its item (14) reads: "Oral drugs or injections for central nervous system stimulants, anorexigenics, and any other agents when used for weight control." The chapter's administrative history records that Regulation .05A was amended most recently effective March 31, 2025.

COMAR 10.09.03.05A(14), Code of Maryland Regulations, Division of State Documents, effective March 2025 · source

The state cites that rule by number itself, and pairs it with what IS covered. Its pharmacy newsletter states: "The Maryland Medicaid fee-for service (FFS) program as well as the state's nine managed care organizations (MCO) cover Wegovy (semaglutide injection) when prescribed to reduce the risk of major adverse cardiovascular events (cardiovascular death, nonfatal myocardial infarction, or non-fatal stroke) in adults with established cardiovascular disease and either obesity or overweight. In accordance with COMAR 10.09.03.05 (A)(14), prescriptions for weight control indications will not be covered at this time." The same closing sentence is repeated in the Fall 2025 edition.

Maryland Department of Health, Pharmacy News & Views, Fall 2024, effective October 2024 · source

The prior authorization form has no weight-loss branch to tick. It offers Wegovy for a patient who "has established cardiovascular disease" with a "BMI of 27kg/m2 or greater within the last 90 days," "Prescribed by or in consultation with a cardiologist"; Wegovy for "non-cirrhotic metabolic dysfunction-associated steatohepatitis (MASH)"; and Zepbound for a patient who "has moderate to severe obstructive sleep apnea (OSA) diagnosed by polysomnography or home sleep study with an apnea-hypopnea index (AHI) ≥ 15 events per hour with obesity" and a "BMI of 30 kg/m2 or greater within the last 90 days." Every branch asks the prescriber to attest that the "Patient has engaged in a trial of weight loss management in the past 6 months and failed to achieve weight loss," and that the patient is "not concurrently using any other GLP-1 receptor agonists." The form's footer reads "MDH - 12/2025."

Maryland Medicaid, Office of Pharmacy Services, Wegovy or Zepbound prior authorization form, effective December 2025 · source

⛔ Maryland's drug list cannot be read as proving non-coverage, and the list says so itself: "Only drugs that are part of the listed therapeutic categories are affected by the Medicaid Preferred Drug List (PDL). Therapeutic categories not listed here are not part of the PDL and will continue to be covered as they always have for Maryland Medicaid participants." The list carries no weight-management category and names no anti-obesity drug — a search of all 33 pages returned zero for Wegovy, Zepbound, Saxenda, obesity and weight, against controls of 7 for insulin and 1 each for Ozempic, Mounjaro and Trulicity. That absence is consistent with the exclusion but does not establish it; the regulation does. The list is marked "Effective Date: 7/1/2026" and "Updated: 8/6/2026."

Maryland Department of Health, Medicaid Preferred Drug List, effective July 2026 · source

The managed care plans run their own formularies, subject to a floor rather than to a common list. COMAR 10.67.06.04 requires that "An MCO shall provide outpatient drugs as defined in §1927(k)(2) of the Social Security Act" and that "An MCO shall establish and maintain a drug formulary that is at least equivalent to the standard therapies of the Maryland Medical Assistance Program." At least equivalent sets a minimum; it does not make nine formularies into one.

COMAR 10.67.06.04, Code of Maryland Regulations, Division of State Documents · source

The weight exclusion is written into the managed care rules as well, so it does not depend on the plan choosing to apply it. The benefits an MCO is not required to provide include "Diet and exercise programs for the loss of weight" and "Prescriptions or injections for central nervous system stimulants and anorectic agents when used for controlling weight."

COMAR 10.67.06.27A, Code of Maryland Regulations, Division of State Documents · source

For a fee-for-service denial the window is 90 days and it runs from RECEIPT rather than from mailing — the opposite anchor to most states on this site. A fair hearing request may not be granted unless it is "Postmarked, delivered in person, or sent by email or facsimile to the Office of Health Services within 90 days of the receipt of the notification specified in Regulation .03A of this chapter, if the appeal concerns services provided or denied by the fee-for-service program."

COMAR 10.01.04.04D(2), Code of Maryland Regulations, Division of State Documents · source

For a managed care denial the plan comes first and the clocks are different again. An MCO must "Require that an enrollee, or a provider acting on the enrollee's behalf, file an appeal within 60 days from the date on the MCO's notice of action." A State fair hearing follows only "after first exhausting the MCO's appeal process," and then the enrollee "shall file for a State fair hearing within 120 days from the date the MCO provides on the written notice of appeal resolution." Keeping benefits running is 10 days at each stage. The rule also deems exhaustion satisfied where the plan misses its own deadlines: "If an MCO fails to adhere to the notice and timing requirements... the enrollee is deemed to have exhausted the MCO's appeals process and may initiate a State fair hearing."

COMAR 10.67.09.05, Code of Maryland Regulations, Division of State Documents · source