Lawsuit challenges insurance restrictions on weight-loss drugs like Wegovy
Many employers and government programs don't cover expensive obesity medications. A lawsuit challenges one of those policies.
Jeannette Simonton was an ideal candidate for the obesity drug Wegovy when her doctor prescribed it for her in February.< /p>
At 5 feet 2 inches tall and weighing 228 pounds, she had a body mass index of nearly 42, well above the threshold approved by U.S. regulators to be eligible to the medicine. She also had serious joint problems after decades of struggling with her weight.
But her insurance refused to pay for the drugs, citing a blanket ban on covering weight-loss drugs . according to a letter Ms. Simonton received in March from her benefits administrator.
Now, Ms. Simonton is suing the Washington state agency that buys insurance illness for public employees like her. . Her lawyers argue that state health plans discriminate against Ms. Simonton — and others like her who seek weight-loss drugs — in violation of state law, which recognizes the Obesity as a type of disability.
Mrs. Simonton's case is a flash point in the dispute over whether health insurance should cover obesity medications. The challenge for payers is that the drugs would be extremely expensive if widely covered in the United States, where more than 100 million people are obese.
The lawsuit is probable. be closely monitored to test whether health plans can refuse to pay for obesity drugs. Ms. Simonton is represented by a Seattle law firm, Sirianni Youtz Spoonemore Hamburger, which has extensive experience challenging health insurance restrictions, including those related to expensive hepatitis C treatments. p>
Wegovy and other appetite suppressant medications are in high demand because they are incredibly effective in helping patients lose weight. But the scale of this demand would pose an unprecedented financial burden on employers and government programs that bear most of the costs of prescription drugs. Wegovy, Novo Nordisk's high-dose version of its popular drug Ozempic, has a sticker price of more than $16,000 a year.
More payers have recently started to cover obesity drugs, encouraged by research suggesting the drugs could pay for themselves in the long term by improving patients' health. But others say they simply can't afford the drugs.
Mrs. Simonton, 57, a nurse who is well-versed in the health benefits of the drugs, said she viewed the refusal to cover her Wegovy as short-sighted.
" They're it's penny and dollar nonsense," she said. "What will they pay in 10, 15 years if I don't continue to lose weight?"
The agency Ms. Simonton is suing, the Washington State Health Care Authority, declined to comment. Ms. Simonton gets her health insurance from the public hospital where she works. As part of her compensation , its hospital pays premiums to the state, which the Health Care Authority uses to pay for its health plan. The agency has authority over which drugs are covered.
Wegovy belongs to a class of injectable drugs known as GLP-1, named after the natural hormone whose effects they mimic. These drugs have been used for years to treat type 2 diabetes, but have more recently been recognized for their extraordinary power to reduce body weight.
Many employers and government programs don't cover expensive obesity medications. A lawsuit challenges one of those policies.
Jeannette Simonton was an ideal candidate for the obesity drug Wegovy when her doctor prescribed it for her in February.< /p>
At 5 feet 2 inches tall and weighing 228 pounds, she had a body mass index of nearly 42, well above the threshold approved by U.S. regulators to be eligible to the medicine. She also had serious joint problems after decades of struggling with her weight.
But her insurance refused to pay for the drugs, citing a blanket ban on covering weight-loss drugs . according to a letter Ms. Simonton received in March from her benefits administrator.
Now, Ms. Simonton is suing the Washington state agency that buys insurance illness for public employees like her. . Her lawyers argue that state health plans discriminate against Ms. Simonton — and others like her who seek weight-loss drugs — in violation of state law, which recognizes the Obesity as a type of disability.
Mrs. Simonton's case is a flash point in the dispute over whether health insurance should cover obesity medications. The challenge for payers is that the drugs would be extremely expensive if widely covered in the United States, where more than 100 million people are obese.
The lawsuit is probable. be closely monitored to test whether health plans can refuse to pay for obesity drugs. Ms. Simonton is represented by a Seattle law firm, Sirianni Youtz Spoonemore Hamburger, which has extensive experience challenging health insurance restrictions, including those related to expensive hepatitis C treatments. p>
Wegovy and other appetite suppressant medications are in high demand because they are incredibly effective in helping patients lose weight. But the scale of this demand would pose an unprecedented financial burden on employers and government programs that bear most of the costs of prescription drugs. Wegovy, Novo Nordisk's high-dose version of its popular drug Ozempic, has a sticker price of more than $16,000 a year.
More payers have recently started to cover obesity drugs, encouraged by research suggesting the drugs could pay for themselves in the long term by improving patients' health. But others say they simply can't afford the drugs.
Mrs. Simonton, 57, a nurse who is well-versed in the health benefits of the drugs, said she viewed the refusal to cover her Wegovy as short-sighted.
" They're it's penny and dollar nonsense," she said. "What will they pay in 10, 15 years if I don't continue to lose weight?"
The agency Ms. Simonton is suing, the Washington State Health Care Authority, declined to comment. Ms. Simonton gets her health insurance from the public hospital where she works. As part of her compensation , its hospital pays premiums to the state, which the Health Care Authority uses to pay for its health plan. The agency has authority over which drugs are covered.
Wegovy belongs to a class of injectable drugs known as GLP-1, named after the natural hormone whose effects they mimic. These drugs have been used for years to treat type 2 diabetes, but have more recently been recognized for their extraordinary power to reduce body weight.
What's Your Reaction?
