California ends Medicaid coverage of weight loss drugs despite TrumpRx plan.

California ends Medicaid coverage of weight loss drugs despite TrumpRx plan.

Changes to Weight Loss Medication Coverage in California

Many low-income people in California who were prescribed very popular weight-loss medications lost their insurance coverage for those medications at the start of the new year.

Recommended alternatives

Health authorities recommend diet and exercise as alternatives to heavily promoted weight loss drugs like Wegovy and Zepbound. Experts say this advice is unrealistic.

"Of course he tried to eat healthy and everything, but now with the medication it's better — a 100% change," said Wilmer Cardenas of Santa Clara, whose husband lost about 100 pounds in about two years with GLP-1s covered by Medi-Cal, California's version of Medicaid.

Financial pressure and medical cuts

California joined several other states in restricting an option they see as no longer affordable as they face rising drug costs and drastic Medicaid cuts under the Trump administration, among other financial pressures. Despite price reductions announced in November that the White House said would make the drugs available at a "dramatically lower cost to taxpayers," states are continuing with the cuts, which providers say are harmful to patients' health.

Impact on patients

"It's going to be very negative for our patients" because data shows that people typically regain weight once they stop taking the medication, said Diana Thiara, medical director of the University of California-San Francisco Weight Management Program.

California, New Hampshire, Pennsylvania and South Carolina have stopped covering adult GLP-1 prescriptions to combat obesity since Jan. 1, but continue to cover the drugs for other health problems, such as type 2 diabetes, cardiovascular disease and chronic kidney disease.

Scope reduction in other states

Michigan, Rhode Island and Wisconsin are planning or considering restrictions, according to the latest KFF poll.

This represents a decrease from 16 states that had coverage for anti-obesity drugs as of Oct. 1. Interest in offering the coverage “appears to be waning,” the survey said, likely due to the cost of the drugs and other budgetary pressures from states.

Price reduction plans

Catherine Ferguson, vice president of federal advocacy for the American Diabetes Association and its affiliated obesity association, said it is unclear how states will respond to the White House's plan to lower the cost of several of the most popular GLP-1s through TrumpRx, an online portal for discounted prescription drugs. For example, Wegovy will be priced at $350 per month for consumers, compared to the current list price of nearly $1,350, and Medicare and Medicaid programs will pay $245.

Challenges for healthcare

“Many states are facing fiscal challenges, such as deficits, and are scrambling to address the impacts of changes to Medicaid and SNAP,” Ferguson wrote, referring to the Supplemental Nutrition Assistance Program (SNAP).

The Department of Health and Human Services referred questions to the White House, which did not respond to requests to end Medicaid coverage for the weight-loss drugs.

California projected that its costs to cover GLP-1s for weight loss would have more than quadrupled in four years, to nearly $800 million annually, had it not ended Medi-Cal coverage for this use. Medi-Cal has covered weight-loss medications since 2006, but use of GLP-1s has only surged in recent years.

Consequences for Medi-Cal members

Medi-Cal members under age 21 will continue to be covered for purposes such as weight loss, California officials said, citing a federal requirement. Medi-Cal members can maintain their GLP-1 coverage if they can demonstrate medical necessity for medical reasons other than weight loss.

Members who have been denied coverage can request a hearing in a letter to members, according to officials.

Members can continue to pay for prescriptions themselves and may be able to take advantage of various discounts to reduce costs. Another option is new obesity treatment pills that will be cheaper than their injectable counterparts. The FDA approved a pill version of Wegovy on Dec. 22 that is expected to cost $149 a month for the lowest dose, and similar weight-loss pills are expected to be available in the first half of the year.

Practical experience

While Cardenas said his husband, Jeffer Jimenez, 37, uses GLP-1s primarily for weight loss, Jimenez's prescription is for his diabetes, so the couple hoped to continue receiving coverage through Medi-Cal.

"He's tried a thousand medications, pills, natural teas and an exercise program, but it doesn't work like the injections," Cardenas said. “You need both.”

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