Notice of Zepbound Coverage, Effective February 5, 2025

By February 5, 2025 (or immediately if date has passed): (1) Billing team must implement prior authorization requirement for all Zepbound claims submitted to Maryland Medicaid FFS and HealthChoice MCOs. (2) Update billing system to flag/require prior auth forms (available at https://bit.ly/4i08QJL for FFS) before claim submission. (3) Create or update claim submission checklist to verify all coverage criteria are met before authorization request: OSA diagnosis via polysomnography with AHI ≥15, current BMI ≥30 kg/m² with height/weight documented within 90 days, prescriber is sleep specialist/pulmonologist/OSA-experienced provider, and no concurrent GLP-1 agonist use. (4) For renewal claims: verify BMI remains ≥30 and obtain prescriber attestation of continued clinical benefit; set system reminders for 6-month renewal windows and annual OSA documentation requirements. (5) Providers must contact MCOs directly for coverage/reimbursement specifics if patients are enrolled in HealthChoice plans. Contact FFS questions to mdh.professionalservicespolicy@maryland.gov or HealthChoice questions to mdh.healthchoiceprovider@maryland.gov. Failure to obtain prior authorization or submit incomplete documentation will result in claim denials.