Insurance Restriction on Wegovy

As reported by the NewYork Times – Jeannette Simonton was a textbook candidate for the obesity drug Wegovy when her doctor prescribed it to her in February.

At 5 feet 2 inches and 228 pounds, she had a body mass index of nearly 42 — well above the cutoff U.S. regulators had approved for eligibility for the medication. She also had serious joint problems after decades of struggling with her weight.

But her insurance refused to pay for the medication, 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 purchases health insurance for public employees like her. Her lawyers argue that the state’s health plans are discriminating against Ms. Simonton — and others who, like her, are seeking weight-loss drugs — in violation of state law, which recognizes obesity as a type of disability.

Ms. Simonton’s case is a flashpoint in the conflict over whether health insurance should have to cover obesity drugs. The challenge for payers is that the medications would be hugely costly if they were broadly covered in the United States, where more than 100 million people are obese.

The lawsuit is likely to be closely watched as a test of whether health plans can refuse to pay for obesity drugs. Ms. Simonton is being represented by a Seattle law firm, Sirianni Youtz Spoonemore Hamburger, that has a long track record of challenging health insurance restrictions, including those for costly hepatitis C cures.

Wegovy and other appetite-suppressing drugs are in huge demand because they are stunningly effective in helping patients lose weight. But the scale of that demand would pose an unprecedented financial burden for the employers and government programs that shoulder most of the costs of prescription drugs. Wegovy, Novo Nordisk’s high-dose version of its popular drug Ozempic, has a sticker price of over $16,000 a year.

More payers have recently begun covering the obesity medications, encouraged by research suggesting that the drugs may pay for themselves in the long run by improving patients’ health. But others say they simply cannot afford to cover the medications.

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Ms. Simonton, 57, a nurse who is well versed on the health benefits of the drugs, said she saw the refusal to cover her Wegovy as shortsighted.

“They’re being penny wise and pound foolish,” she said. “What will they be paying in 10, 15 years if I don’t continue to lose the weight?”

The agency Ms. Simonton is suing, the Washington State Health Care Authority, declined to comment. Ms. Simonton gets her health insurance through the public hospital where she works. As part of her compensation, her hospital pays premiums to the state, which the Health Care Authority uses to pay for her health plan. The agency has authority over which drugs are covered.

Wegovy is in a class of injectable drugs known as GLP-1s, named after the natural hormone whose effects they emulate. The drugs have been used for years to treat Type 2 diabetes but more recently have been recognized for their extraordinary power to slash body weight.

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About 36 million people with Type 2 diabetes in the United States — as well as about 18 million who are obese but not diabetic — have access to GLP-1s through their health plans, according to analysts at the investment bank Jefferies. That is about 17 percent of the country’s insured people.

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