California Ends Medicaid Coverage for Weight Loss Drugs Despite TrumpRx Plan

SACRAMENTO, Calif. — Many low-income Californians who were prescribed hugely popular weight loss drugs lost their drug coverage at the start of the new year.

Health officials recommend diet and exercise as alternatives to highly-advertised weight-loss drugs like Wegovy and Zepbound, but experts say they’re unrealistic.

“Of course he tried to eat well and everything, but now with the medications, it’s better — 100 percent change,” said Wilmer Cardenas of Santa Clara, who said his husband lost about 100 pounds over about two years using GLP-1s covered by Medi-Cal, California’s version of Medicaid.

California has joined several other states in restricting an option they say is no longer affordable for everyone, as it faces high drug costs and rising drug costs Steep Medicaid cuts Under the Trump administration, among Other financial pressures. Despite negotiated price cuts announced in November The White House said It would make the drugs available at “significantly lower cost to taxpayers” and enable Medicaid to cover them, and states are moving forward with cuts, which providers say could undermine patients’ health.

“It would be very negative for our patients,” he said, because the data shows that people usually regain weight after stopping medications Diana Thiaramedical director of the Weight Management Program at the University of California-San Francisco.

While California, New Hampshire, Pennsylvaniaand South Carolina It stopped covering adult GLP-1 prescriptions for obesity on January 1, and continues to cover drugs for other health problems, such as type 2 diabetes, cardiovascular disease, and chronic kidney disease.

Michigan, rhode islandWisconsin is planning or considering restrictions, according to KFF’s Latest poll.

This reverses a trend that saw 16 states cover obesity medications as of October 1. The survey found that interest in providing coverage “appears to be waning,” likely due to the cost of medications and other pressures on the state budget. North Carolina withdrew GLP-1 coverage in October, however Governor Josh Stein It was reinstated in December, complying with court orders despite the persistent budget deficit.

It’s not clear how states will adapt to the White House’s plan to lower the cost of many of the most popular GLP-1s through TrumpRx, an online portal for discounted medications, said Katherine Ferguson, vice president of federal advocacy for the American Diabetes Association and its Obesity Association. For example, Wegovy will be priced at $350 per month for consumers, versus its current list price of about $1,350, and Medicare and Medicaid will pay $245, according to the plan.

“Many states are facing budget challenges, such as deficits, and are working to address the effects of changes to Medicaid and SNAP,” Ferguson wrote, referring to the Supplemental Nutrition Assistance Program. “As more details become available about the management agreements, we will see how the state responds to Medicaid.”

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

California has projected that the costs of covering GLP-1 weight loss will more than quadruple over four years Nearly $800 million annually If you do not end your Medi-Cal coverage for this use. Medi-Cal has covered weight-loss drugs since 2006, but the use of GLP-1s has only risen in recent years. By 2024, Medi-Cal has covered more than 645,000 prescriptions across all drug uses. The California Department of Health Care Services was unable to provide details on whether the medications were for weight loss or other conditions.

When asked whether the state would reconsider its plans in light of the announced rate cuts, Treasury spokesman H.D. Palmer said it had no plans to do so. The California pieces were written in State budget law.

California officials did not say how much you could save under the TrumpRx plan, citing federal and state restrictions on disclosing deductible information.

Health providers don’t expect the price cuts negotiated by the Trump administration to make much difference to consumers, because drug companies are already offering some discounts.

“Out-of-pocket costs will still be very prohibitive for most people, especially individuals with Medicaid insurance,” Thiara said.

New Hampshire It is among other states that ended its coverage on January 1. Officials with the New Hampshire Department of Health and Human Services did not respond to requests for comment.

About 1 in 8 adults now take a GLP-1 drug to treat obesity, disease, or both, up 6 percentage points from May 2024, according to KFF poll results Released in November. More than half of users said their GLP-1 treatments were difficult to afford, and many of those who discontinued treatment cited the cost.

Public and private payers have tried to do this Wean patients To save costs. Medi-Cal members and their health care providers, California health officials said You should look “Other treatment options that can support weight loss, such as diet changes, increasing activity or exercise, and counseling.” This reflects New Hampshire Medicaid advice.

California Department of Health Care Services spokeswoman Tessa Otis said in an email that the official advice to try those other approaches now “is not intended to dismiss any prior efforts, but to encourage Medi-Cal members to take a renewed, proactive, medically supported approach with their health care provider that may appropriately include these additional options.”

But that may be unrealistic, he said Kurt Hongfounding director of the Center for Clinical Nutrition at the Keck School of Medicine of the University of Southern California.

“We definitely want patients to do their part with diet and exercise, but unfortunately, from a practical standpoint, that in itself is often not enough,” Hong said, adding that by the time patients see doctors, they have already failed to achieve results through those means.

Hong understands why Medicaid programs, as well as private providers, might want to reduce drug coverage, which can be costly Thousands of dollars For each patient annually. However, they can produce twice the weight loss compared to previously commonly used medications.

One school of medical thought advocates patients gradually stopping their use, but Hong said obesity is generally considered a chronic condition that requires non-specific treatment.

“Once they reach their target weight, many people will try to figure out whether or not they can wean,” Hong said. “We see a lot of patients — when they try to get off, unfortunately, the weight comes back on.”

Medi-Cal members under age 21 Stay covered For purposes including weight loss, California officials said, citing a federal requirement.

Medi-Cal members are able to keep their GLP-1 coverage if they can prove it’s medically necessary for purposes other than weight loss, the department said. Members who have been denied coverage can request a hearing, the department said message For members.

Members will still be able to pay for prescriptions Out of pocket They may be able to use various discounts to reduce costs. The other option is new obesity pills, which will be cheaper than their injectable counterparts. the FDA approved A pill version of Wegovy is due Dec. 22, which will likely cost $149 per month for the lowest dose, and similar weight-loss pills are expected to be available in the first half of the year.

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

“He tried thousands of medications, pills, natural teas, and an exercise program, but it didn’t work as well as the injections,” Cardenas said. “You need both.”