Diabetes Prevention Program (DPP) benefit
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This policy describes Maryland Physicians Care's statewide benefit offering for a year-long Diabetes Prevention Program for members aged 18-64 who have prediabetes or are at risk for type 2 diabetes and do not already have diabetes. It governs provider referrals to recognized MDH DPP programs and program delivery expectations.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial Eligibility
Covered when ALL of the following are met
statewide benefit
Member must not already have diabetes
Members previously diagnosed with diabetes do not qualify
Program Structure
Program must meet the following delivery elements
Coaches may be health professionals or non-licensed personnel
Members are not eligible for the Diabetes Prevention Program benefit if they have a prior diagnosis of diabetes or are currently pregnant. This exclusion applies to all referrals and enrollments; providers should confirm that the member does not already have diabetes and is not pregnant before referring to a Recognized National DPP provider.
Provider Actions & Administrative Requirements
Prior authorization not specified; provider referral required
No prior authorization requirement is specified in this policy; providers refer eligible members to Recognized National DPP provider programs per MDH DPP requirements.
No step therapy required
The policy does not describe any step therapy requirements for participation in the DPP benefit.
Refer eligible members to Recognized National DPP programs
Providers may refer members aged 18–64 who have prediabetes or are at risk for type 2 diabetes and who do not already have diabetes to Recognized National DPP provider programs that meet MDH DPP requirements.
- Program is year‑long and delivered in‑person or online.
- Includes a minimum of 16 weekly sessions in the first six months and at least six monthly sessions in the second six months.
- Delivered by trained lifestyle coaches with group support (group size 10–25).
Ineligible: existing diabetes or pregnancy
Members previously diagnosed with diabetes or who are currently pregnant are not eligible for the DPP benefit and should not be referred for this program.
Definitions
Background
The Diabetes Prevention Program (DPP) is a year-long prevention program offered to members aged 18–64 years who have prediabetes or are otherwise at risk for type 2 diabetes but do not already have diabetes. The program may be delivered in-person or online and is led by trained lifestyle coaches (health professionals or non-licensed personnel) with group support (typical group size 10–25 participants).
Program structure requirements include a minimum of 16 weekly sessions during the first six months and at least 6 monthly sessions during the second six months. Providers may refer eligible members to Recognized National DPP providers in the MPC network that meet Maryland Department of Health DPP requirements.
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