Janet Simonton became a textbook candidate when her doctor prescribed the obesity drug Wegoby in February.
At 5 feet 2 inches tall and weighing 228 pounds, she had a BMI of nearly 42, well above the threshold that U.S. regulators have deemed eligible for treatment. She also had severe joint problems as she had struggled with her weight for decades.
But Simonton’s insurance refused to pay for the weight-loss drugs, citing a blanket ban on coverage, according to a letter she received from her benefits administrator in March.
Now, Simonton is suing the Washington state agency that buys health insurance for public servants like her. Her lawyers argue that the state health plan discriminates against Ms. Simonton and others like her seeking weight-loss drugs, violating state law that recognizes obesity as a disability. .
Simonton’s case has become a flashpoint in a dispute over whether health insurance should cover obesity drugs. The challenge for payers is that widespread drug coverage would be costly in the United States, where more than 100 million people are obese.
The case is likely to be closely watched as a test of whether health insurance companies can refuse to pay for obesity drugs. Mr. Simonton is represented by the Seattle law firm Sirianni Utes Spoonmore Hamburger. The law firm has a long history of challenging health insurance restrictions. Expensive treatments for hepatitis C.
Wegovy and other appetite suppressants are in great demand because they are surprisingly effective in helping patients lose weight. But the scale of that demand will place an unprecedented financial burden on employers and government programs that pay for most of the costs of prescription drugs.The list price for Wegoby, a high-dose version of Novo Nordisk’s popular drug Ozempic, is Over $16,000 one year.
More payers have recently begun covering obesity drugs, encouraged by research suggesting the drugs may pay for themselves in the long run by improving patient health. However, some people say they cannot afford to pay for their medicines.
Ms Simonton, 57, a nurse who is knowledgeable about the health benefits of drugs, said she thought Wegoby’s refusal to be interviewed was short-sighted.
“They’re every penny wiser and every penny wiser,” she said. “If I don’t keep losing weight, what are they going to pay me in 10, 15 years?”
The agency Simonton is suing, the Washington State Department of Health Services, declined to comment. Simonton has health insurance through the public hospital where he works. Her hospital pays premiums to the state as part of the coverage, which health officials use to pay for her health insurance. The agency has the authority to decide which drugs are covered.
Wegovy is a type of injectable drug known as GLP-1, named after the natural hormone whose effects it mimics. These drugs have been used for years to treat his type 2 diabetes, but have recently been recognized for their extraordinary power to reduce weight.
About 36 million people in the U.S. with type 2 diabetes and about 18 million people who are obese but do not have diabetes can receive GLP-1 through their health insurance, according to analysts at investment bank Jefferies. This corresponds to approximately 17% of the insured population in Japan.
Federal law prohibits Medicare from paying for weight-loss drugs, and that ban remains in place largely because of the staggering cost. If Congress overturned the ban, One prediction from academic researchers An estimated 2 million Medicare beneficiaries (10 percent of obese seniors) will use Wegovy. That would cost the government $27 billion a year, nearly one-fifth of the annual spending for Medicare’s Part D program, which covers prescription drugs taken at home.
State health insurance programs for employers and public employees face similar dilemmas.In Arkansas, 40% of people on state employee plans are obese, making it expensive to cover medications $83 million Every year.of wisconsin The program needs to come up with additional $25 million Every year.
“Employers are not suddenly going to have new funds to cover rising health insurance premiums,” said Dr. Stephen Pearson, director of the Institute for Clinical and Economic Review, which assesses the value of drugs. “We’re talking about major changes in companies’ ability to provide other benefits, wage increases, and new jobs. And companies will be able to translate that into higher premiums for their own employees. You may need it.”
Another concern for employers is that they may not realize the savings from investing in weight loss drugs. Even if a drug averts a heart attack or avoids hospitalization, the savings may not show up until the patient leaves his or her employer years later.
But advocates for obese patients see bias and prejudice at work when medical plans equate weight-loss treatments with unnecessary vanity.
Simonton, who lives in Ellensburg, Wash., has struggled with obesity for as long as she can remember. At one point in her 40s, she weighed 424 pounds. After she had surgery to reduce her stomach, her weight fluctuated over 250 pounds for years.
The weight became a burden. His osteoarthritis was so severe that the bones in his knees were rubbing against each other, so he has already had his right knee replaced and surgery on his left knee scheduled for next month. “She wondered if she would still be a nurse,” she says.
Last year, she started taking Mounjaro, another powerful GLP-1 drug, and most of the cost was covered by the drug’s manufacturer, Eli Lilly. When that assistance ran out, she paused her treatment, during which time her doctor helped Novo seek insurance coverage for her Nordisk medications.
In February, frustrated by the lack of progress, Simonton began spending money out of his own pocket to obtain Novo Nordisk drugs from a compounding pharmacy.
Since starting taking the GLP-1 drug in September 2022, she has lost 76 pounds. Her current weight is 191 pounds.
“My life has changed in an amazing way,” she said. “This is the first time I’m not thinking about food all the time.”
But to cover the nearly $2,000 out-of-pocket costs so far, Simonton and her husband have cut back on their grocery spending and diluted their retirement savings.
Simonton’s lawsuit, filed last month in state court in Washington, seeks to force her health insurance to pay Wegobee’s future premiums and reimburse her when she is denied coverage. Her lawyers are seeking class action status on behalf of people like her who buy insurance for public employees and school employees in Washington state.
In 2019, the Washington State Supreme Court ruled that obesity is “always” a protected disability under the state’s anti-discrimination law. Other courts outside the state have ruled that obesity is generally not protected.
