Pediatric Research Update: Using Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) to Improve Access to Obesity Pharmacotherapy

Article Summary

Obesity pharmacotherapy for youth on Medicaid is often excluded. However, EPSDT, a federal provision that mandates coverage of medically necessary treatment for Medicaid enrollees under 21, has been used successfully in some states to obtain coverage of anti-obesity medications otherwise excluded.

Read full article

Article Review

Arguably, one of the biggest frustrations encountered when treating patients with obesity is the financial barrier to accessing pharmacotherapy. This affects low-income families disproportionately; children who rely on Medicaid are both at higher risk of developing obesity and less likely to access treatment because Medicaid coverage of obesity medications varies from state to state. This can potentially be ameliorated by a provision known as EPSDT (Early and Periodic Screening, Diagnostic, and Treatment), which is federally mandated and requires coverage for medically necessary services through Medicaid for individuals under 21 years of age, even when those services are not included as part of the state’s Medicaid benefits. However, many clinicians are not aware of how to use this provision, or find the process complex and time-consuming.

Through this article, Moore et al. review practical steps to apply for medication authorization based on the EPSDT provision, potential challenges and limitations, and look at EPSDT on a broader level in the healthcare and policy landscapes. The guide draws on federal EPSDT policy, state-level examples, and workflows from centers that have successfully obtained coverage. The authors detail a step-by-step process that includes identifying eligible patients, documenting medical necessity, submitting prior authorization requests, and managing appeals. They provide examples of how EPSDT for anti-obesity medication works in three different states (Colorado, California, and Maine), as well as supplementary tools, including sample letters of medical necessity and documentation templates that align with EPSDT statutory language. Specifically, the letter of medical necessity should include that EPSDT is being invoked and that the requested treatment is not covered under standard Medicaid. It should also describe obesity severity and comorbidities, prior treatment attempts, and the rationale for the specific medication. Each state may have different processes and forms that are required to use this provision, and the differences can be significant: Colorado accepts a direct EPSDT request without a prior denial, whereas California’s process typically follows or accompanies a denial of standard coverage. Appendix C in the article includes links for state-specific guidance. Having a defined team, which can be as small as the prescriber and one staff member, and an efficient workflow is crucial to navigating these systems.

Each state can use its discretion in how to interpret what is considered medically necessary under EPSDT. At the same time, the Centers for Medicare and Medicaid Services State Medicaid Manual states that services cannot be denied arbitrarily or reduced solely because of a diagnosis or condition, and the authors argue that this extends to obesity medications when they are medically necessary. States may still use utilization controls, such as prior authorization and clinical eligibility criteria, as long as these do not effectively deny access to necessary care.

State examples show how much this varies. Colorado generally follows FDA labeling and the 2023 American Academy of Pediatrics (AAP) Clinical Practice Guideline without added thresholds. In California, Medi-Cal ended routine coverage of obesity medications on January 1, 2026, so all pediatric requests now go through EPSDT, and the authors report that approval currently requires an FDA-approved indication and a BMI of at least 30 kg/m². In Missouri, clinicians partnered with the state Medicaid pharmacy program, which led to coverage of GLP-1 receptor agonists in January 2025, although new prescriptions were narrowed in early 2026 for budget reasons.

Even with access to medication under this provision, once patients turn 21, they risk losing access to this medication. EPSDT does not extend to young adults beyond age 21 years, and the authors also note that the Children’s Health Insurance Program (CHIP) has no EPSDT equivalent and that any move to a different insurance plan can interrupt treatment. Because obesity is chronic and relapsing, the authors warn that an abrupt loss of coverage may lead to weight regain and escalation of obesity and its complications. Thus, anticipatory guidance regarding the possibility of losing access should be given to older adolescents, with help planning next steps where possible, and advocacy efforts to increase access to medication for all people must continue. Such advocacy efforts may include partnering with the state AAP chapter, presenting clinic data to state Medicaid advisory boards, or working with a health system’s government relations department to increase awareness of the benefits of anti-obesity pharmacotherapy and potential for long-term cost savings by reducing or preventing obesity-related complications. The authors also acknowledge that medication cost is a real barrier for state Medicaid programs and that pediatric economic data remain limited.

The authors note that the guide relies largely on policy analysis, clinical experience, and selected state examples rather than systematic national data, and that state policies are changing quickly. Even so, the practical message is clear: when an eligible patient needs obesity pharmacotherapy, start the EPSDT process early, document medical necessity clearly, and appeal denials.