MedicaidCoverageMedium impact
Coverage of Imcivree for Monogenic or Syndromic Obesity
Maryland Medicaid·MD · Endocrinology, Pediatrics, Genetics +2 more·FQHC
Effective date
Apr 1, 2024
We identified it
Sep 5, 2026
Summary
Maryland Medicaid is reminding providers that Imcivree coverage for monogenic or syndromic obesity has been in effect since April 1, 2024. This transmittal clarifies FDA-approved indications (acquired hypothalamic obesity, Bardet-Biedl syndrome, and POMC/PCSK1/LEPR deficiency) and specifies billing codes: NDC for FFS programs and HCPCS J3490 for MCO medical benefits.
Action Required
By September 4, 2026 (transmittal date): Billing team must ensure awareness of Imcivree coverage and billing requirements. (1) For Medicaid FFS claims: Bill Imcivree using the most current NDC. (2) For MCO claims where Imcivree is covered under medical benefit: Bill using HCPCS Code J3490. (3) For MCO plans: Contact the specific MCO directly to confirm their reimbursement policies, as MCOs determine their own coverage. (4) Verify patient eligibility for Imcivree based on FDA-approved indications only: acquired hypothalamic obesity (age 4+), Bardet-Biedl syndrome (age 2+), or confirmed POMC/PCSK1/LEPR deficiency with pathogenic/likely pathogenic/uncertain significance variants (age 2+). Reject claims for other obesity types or benign/likely benign genetic variants. Forward FFS billing questions to mdh.professionalservicespolicy@maryland.gov. This is a clarification of existing policy (effective April 1, 2024), so no retroactive claim adjustments are required.