Pennsylvania has quietly moved to limit access next year to popular weight-loss drugs like Ozempic and Wegovy for residents covered by Medical Assistance, the state\u2019s Medicaid plans. Beginning in January, Medicaid will no longer pay for adults to take the drugs for obesity only, but coverage will continue for diabetes and other conditions.<\/p>\n
The move is an effort to reduce Medicaid costs, which have been driven higher by the popular but pricey medication known as GLP-1 receptor agonists. Under a plan first proposed by Gov. Josh Shapiro\u2019s administration<\/a> this year, it\u2019s expected to reduce the more than $1.3 billion the state expects to spend on the medications this year.<\/p>\n The move is likely to be controversial: Legislators already hotly debated the costs of covering the drug<\/a> during budget hearings.<\/p>\n \u201c\u200aTo simply restrict coverage is penny-wise and pound-foolish,\u201d said McCandless state Rep. Arvind Venkat, who also works as an emergency physician. Venkat said he understands the concern around cost, but \u201cthese medications are proven to prevent severe illnesses, and the savings will be obvious as more people who are eligible to use these medications do so\u201d for heart disease, kidney disease and other comorbidities.<\/p>\n Venkat said he\u2019s heard from members of the public who have received letters about the benefit cut, but there\u2019s been little public discussion of the change, and the form letter\u2019s language isn\u2019t entirely clear.<\/p>\n \u201cIf DHS is restricting access, they owe it to the public to explain what their rationale is,\u201d Venkat said.<\/p>\n A copy of a letter sent by a health system, reviewed by WESA, says \u201cDrugs containing a GLP-1 receptor agonist for the treatment of overweight or obesity will no longer be covered unless you also have a condition for which GLP-1 receptor agonist remains a covered prescription drug benefit.” It identifies some name-brand drugs including Ozempic and Wegovy.<\/p>\n The letter does not explain a reason for the change, but does notify recipients that coverage for the drug will end Dec. 31 \u201cunless your doctor requests a new prior authorization and the GLP-1 drug is authorized.\u201d It also notifies them of deadlines for appealing the move.<\/p>\n \u201cNotices are being delivered to Medicaid recipients affected by this change this month that will outline the change and appeal processes,\u201d a DHS spokesperson confirmed Thursday evening.<\/p>\n The change was announced with little fanfare in a state Department of Human Services bulletin<\/a> sent last week by state Medicaid director Sally Kozak to health care providers. Other obesity meds that are not GLP-1 medications will be covered if they are on the state\u2019s preferred drug list.<\/p>\n The move comes months after an April meeting of the Pharmacy and Therapeutics committee of the state Department of Human Services. More than two dozen doctors voted on the proposed change, and minutes from that meeting suggest that cost was a driving factor.<\/p>\n \u201cThe current price and utilization of GLP-1s has contributed to budget growth at a rate that is unsustainable,\u201d the meeting summary asserted. It showed that when GLP-1s were used solely to treat diabetes, they cost the state Medicaid program $223.3 million in 2022. Once Medical Assistance agreed to cover use of the drug to treat overweight and obesity in 2023, the cost spiked to $650 million over the next two years. In 2025, the bill topped $1.3 billion, the summary said.<\/p>\n Other states, such as Wisconsin and Rhode Island, have considered restricting coverage<\/a> as well. As of October 16 states<\/a>, including Pennsylvania at the time, offered GLP-1 coverage for obesity. Medicaid covers the drugs for some uses \u2014 but not obesity alone \u2014 in New Mexico, Texas, Connecticut, North Carolina and North Dakota, according to a KFF policy analysis<\/a> published last month.<\/p>\n Some in Pennsylvania have hailed the move.<\/p>\n State Sen. Scott Martin (R-Lancaster), who chairs the upper chamber\u2019s Appropriations Committee, had questioned the way the state covers the weight-loss drugs<\/a> during budget hearings earlier this year. \u201cThere\u2019s certainly other ways that people can engage in healthier living to lose weight without the taxpayers paying for a magic shot,\u201d he said at the time.<\/p>\n In a statement Thursday, he called the reform \u201ca step in the right direction.\u201d<\/p>\n \u201cWe absolutely should be taking a closer look at how GLP-1s are being prescribed and what should be covered under a government safety net program like Medicaid, paid for by taxpayers,\u201d Martin said. \u201cHuman services costs are some of the fastest-growing expenses in the state budget, so we need to find common-sense reforms like this to get spending under control.\u201d<\/p>\n Squirrel Hill state Rep. Dan Frankel, a Democrat who chairs the House Health committee, said the cost of the drug was too hard a pill for lawmakers to swallow.<\/p>\n While the medication has \u201cextraordinary benefits for Pennsylvanians,\u201d he said, \u201cat the end of the day, it’s a budget buster,\u201d he said. That\u2019s especially true \u201c\u200ain an environment where state resources can’t really fill the gaps \u2026 that are being foisted on us from Washington.\u201d<\/p>\n By next fall, the Trump administration will add extra work requirements and other cost-cutting rules to Medicaid, which Frankel said threaten coverage for nearly 700,000 Pennsylvanians. And the state will also have to absorb new requirements for food benefits<\/a> the administration has already rolled out.<\/p>\n