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's 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.
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's administration this year, it's expected to reduce the more than $1.3 billion the state expects to spend on the medications this year.
The move is likely to be controversial: Legislators already hotly debated the costs of covering the drug during budget hearings.
" To simply restrict coverage is penny-wise and pound-foolish," said McCandless state Rep. Arvind Venkat, who also works as an emergency physician. Venkat said he understands the concern around cost, but "these 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" for heart disease, kidney disease and other comorbidities.
Venkat said he's heard from members of the public who have received letters about the benefit cut, but there's been little public discussion of the change, and the form letter's language isn't entirely clear.
"If DHS is restricting access, they owe it to the public to explain what their rationale is," Venkat said.
Letter does not explain reason
A copy of a letter sent by a health system, reviewed by WESA, says "Drugs 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.
The letter does not explain a reason for the change, but does notify recipients that coverage for the drug will end Dec. 31 "unless your doctor requests a new prior authorization and the GLP-1 drug is authorized." It also notifies them of deadlines for appealing the move.
"Notices are being delivered to Medicaid recipients affected by this change this month that will outline the change and appeal processes," a DHS spokesperson confirmed Thursday evening.
The change was announced with little fanfare in a state Department of Human Services bulletin 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's preferred drug list.
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.
"The current price and utilization of GLP-1s has contributed to budget growth at a rate that is unsustainable," 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.
Other states, such as Wisconsin and Rhode Island, have considered restricting coverage as well. As of October 16 states, including Pennsylvania at the time, offered GLP-1 coverage for obesity. Medicaid covers the drugs for some uses — but not obesity alone — in New Mexico, Texas, Connecticut, North Carolina and North Dakota, according to a KFF policy analysis published last month.
'A step in the right direction'
Some in Pennsylvania have hailed the move.
State Sen. Scott Martin (R-Lancaster), who chairs the upper chamber's Appropriations Committee, had questioned the way the state covers the weight-loss drugs during budget hearings earlier this year. "There's certainly other ways that people can engage in healthier living to lose weight without the taxpayers paying for a magic shot," he said at the time.
In a statement Thursday, he called the reform "a step in the right direction."
"We 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," Martin said. "Human 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."
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.
While the medication has "extraordinary benefits for Pennsylvanians," he said, "at the end of the day, it's a budget buster," he said. That's especially true " in an environment where state resources can't really fill the gaps … that are being foisted on us from Washington."
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 the administration has already rolled out.
Other efforts to rein in the drugs' costs have made little headway. Frankel has long sought reforms such as prescription cost regulations, similar to the regulatory oversight imposed on public utilities. And Venkat has sponsored a bipartisan bill that would reduce the state's cost of GLP-1s by using a medication subscription model that would cap the price. That legislation has not yet been considered in the House Human Services committee.
Patients who believe they've received a notification from DHS in error may be able to appeal, according to Kyle Fisher, managing attorney at the Pennsylvania Health Law Project. Those under 21 should still be able to receive the medication for obesity and overweight, he said. So should adults with related health concerns.
"If they have a condition other than weight loss that the GLP-1s are approved for — such as … diabetes or sleep apnea or cardiac risk factors — they should certainly work with their clinicians," Fisher said.
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