A woman is suing her health insurer for refusing to cover the weight-loss drug Wegovy prescribed by her doctor to treat her obesity.
Jeannette Simonton, a nurse from Kittitas County, Washington, weighed 228 pounds when her doctor prescribed Wegovy in February. Her weight and height gave her a body mass index (BMI) of almost 42, putting her above the threshold of 30 that US regulators had approved as the minimum for the medication.
She also suffered from joint problems after decades of being overweight.
However, Ms. Simonton was insured under the Washington State Health Care Authority, a state health insurance plan, which does not cover treatments for obesity.
Jeannette Simonton, a nurse from Kittitas County, Washington, was prescribed Wegovy by her doctor in February 2023. She is pictured here in a photo posted to Facebook in 2017.
Since taking Wegovy, Ms. Simonton has been able to have knee replacement surgery
She started paying for her Wegovy prescription out-of-pocket, which cost her almost $2,000, and lost 80 pounds on the drug. After her weight loss, she was able to have a total knee replacement to address her joint pain.
Mrs Simonton said: ‘I feel great. I feel like I’m getting my life back. I am much more active, I can swim. I started exercising a lot more. Since then I have been able to have my first total knee done and that has given me a lot of freedom so that I can now actually go for walks.’
However, in March, her health insurance informed her that the medication would not be covered, citing a blanket ban on weight-loss drugs.
Discovering this was “so disappointing,” she said.
Dr. Peter Billing, a bariatric and weight loss specialist, told NewsNation that insurance companies should cover the medication.
He said: ‘It discriminates against people who are obese and it is completely wrong.
‘The thinking is that people are obese because they are lazy. They don’t reduce what they eat or exercise. It couldn’t be further from the truth.
“(Obesity) is a medical disease with biological markers that show that disease exists, and Ozempic and Wegovy… treat that disease.”
The Affordable Care Act and a similar law passed in Washington state made it illegal for health insurers to discriminate on the basis of a disability or serious health condition.
Under Washington state law, obesity is categorized as a disability and the lawsuit argues that denial of coverage is an unlawful form of discrimination.
“Today, health insurers must base their decisions on whether the treatment is medically effective or not,” Ms. Simonton’s lawyer, Ele Hamburger, explains.
“The science here is so clear that the only reason to continue to rule out these types of treatments for a recognized serious medical condition is discrimination. It is discrimination based on disability.”
After paying for her Wegovy prescription herself for several months, she sued the insurer in September, but admitted that if she doesn’t win the lawsuit, she will continue to pay for it herself and not stop taking it.
Demand for Wegovy and other appetite suppressant medications has skyrocketed.
But with Because 42 percent of American adults are obese, insurance companies are reluctant to cover the enormous price tag. The list price for a month’s supply of Wegovy in the US is $1,349 per patient, while the comparable drug Ozempic costs $936.
Only some private insurers cover medications such as Wegovy and Ozempic, but some federal and state insurance programs such as Medicaid and Medicare do not.
Wegovy, which was originally only approved for diabetes, is also approved for weight loss, while Ozempic is only approved by the Food and Drug Administration (FDA) to treat type 2 diabetes, although it is prescribed off-label for weight loss.
Most private insurance companies cover some or all of the cost of the medications if they are prescribed for type 2 diabetes, but usually do not cover weight loss.
According to a benefits consultant cited by the Associated Press, less than half of employer health plans cover obesity medications.