A woman is suing her health insurance company for refusing to cover the weight loss drug Wegovy that her doctor prescribed to treat her obesity.
Jeannette Simonton, a nurse in Kittitas County, Washington, weighed 228 pounds when her doctor prescribed Wegovy in February. Her weight and height meant she had a body mass index (BMI) of almost 42, putting her above the threshold of 30, which US regulators had approved as a minimum for the drug.
He also suffered from joint problems after decades of being overweight.
However, Ms. Simonton was insured by the Washington State Health Care Authority, a health insurance provided by the state, which does not cover any obesity treatment.
Jeannette Simonton, a nurse in Kittitas County, Washington, was prescribed Wegovy by her doctor in February 2023. She is seen here in a photo posted to Facebook in 2017.
Since taking Wegovy, Ms Simonton was able to undergo knee replacement surgery.
She started paying for her Wegovy prescription herself, which cost her nearly $2,000, and lost 80 pounds on the medication. After losing weight, she was able to undergo a total knee replacement to treat her joint pain.
Mrs Simonton said: ‘I feel amazing. I feel like I’m getting my life back. I am much more active, I can swim. I have started exercising a lot more. Since then I was able to have my first total knee operation and that freed me up, so now I can go out and walk.’
However, in March, her health insurance informed her that the medication would not be covered, citing a complete ban on weight-loss medications.
Finding this out was “very disappointing,” he said.
Dr. Peter Billing, a bariatric doctor and weight loss specialist, told NewsNation that insurance companies should cover the drug.
He said: “It is discriminatory against obese people and it is totally wrong.”
‘The idea is that people are obese because they are lazy. They don’t reduce what they eat and they don’t exercise. It couldn’t be further from the truth.
“(Obesity) is a medical disease with biological markers that show that disease and Ozempic and Wegovy… treat that disease.”
The Affordable Care Act and a similar law passed in Washington state made it illegal for health insurance companies to discriminate on the basis of disability or serious health condition.
Under Washington state law, obesity is classified as a disability, and the lawsuit argues that denial of coverage is an illegal form of discrimination.
“Today, health insurers have to base their decisions on whether the treatment is medically effective or not,” explained Simonton attorney Ele Hamburger.
‘The science here is so clear that the only reason to continue to exclude this type of treatment for a recognized serious medical condition is discrimination. It is discrimination on the basis of 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 won’t stop taking it.
Demand for Wegovy and other appetite suppressant drugs has skyrocketed.
But with For the 42 percent of American adults who are obese, insurance companies are reluctant to cover the enormous price tag. The list price for Wegovy’s monthly supply in the United States is $1,349 per patient, while the similar 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, has also been 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 lose weight.
Most private insurance companies cover some or all of the cost of medications when prescribed for type 2 diabetes, but generally do not cover weight loss.
According to a benefits consultant cited by the Associated Press, less than half of employer health insurance plans cover obesity medications.