Woman sues Wegovy to get health insurance to cover her

Amid a months-long shortage of semaglutide diabetes and weight loss medications, a woman is suing her insurer for failing to cover the drugs.

As theNew York Times According to reports, Washington state nurse Jeannette Simonton was told her insurer was completely banning weight-loss drugs and would not cover her prescription for Wegovy, the injectable semaglutide that was swept off shelves this year.

So now she’s suing the Washington State Health Care Authority, the agency responsible for underwriting health insurance for public employees, for discrimination, arguing that obesity is a legally recognized disability in Washington state and that insurance must so cover it. Simonton’s specific employer, but could also be a sign of things to come across the country.

Semaglutide, the crucial ingredient in Wegovy and its sister diabetes drug, Wegovy, belong to a class of drugs called glucagon-like peptide-1 agonists, or GLP-1 agonists for short. Originally used as a diabetes medication because of its ability to lower blood sugar levels, semaglutide for weight loss was approved by the Food and Drug Administration in 2021 after drugmakers discovered that it also helped patients feel full and eat less.

Over the past few years, Wegovy and Ozempic have made headlines and memes as more and more people, about 1.7 percent of the total U.S. population, or 5.68 million people, see each other prescribe this injectable medication that many users consider a revolution in the world. weight management.

Despite all these prescriptions, Wegovy and Ozempic are increasingly difficult to acquire due to an industrial shortage. And those who are lucky enough to find them in pharmacies are often forced to pay out of pocket for this medication, which can cost more than $1,000 a month, because their insurers, like Simonton’s, refuse to cover them.

“They are being careful and crazy,” the 57-year-old nurse told the newspaper. New York Times. “What will they pay in 10, 15 years if I don’t continue to lose weight?”

Simonton’s argument is a common one: the hefty cost of the drug, which has no generic, will ultimately save him and his insurer money because it will eliminate the problems of health linked to obesity.

She may be right, but not all experts agree.

“These drugs are incredibly expensive and desired by a ton of patients, and patients will never be able to live without them,” said James Gelfand, president and CEO of the employer advocacy group ERISA Industry Committee. Insider during the summer. “Pharmaceutical companies, providers and patient groups insist that weight loss will improve health and therefore offset these enormous costs. This is not true.”

Simonton ultimately decided to go to a compounding pharmacy to obtain an unauthorized GLP-1 agonist. But even this off-label version had a cost: the nurse told the New York Times that she has paid almost $2,000 out of pocket so far and has had to dip into her retirement fund and even spend less on groceries to cover that.

In her lawsuit against the state health agency, Simonton seeks to recoup money she has already paid out and force the state to pay for state employees’ Wegovy prescriptions in the future, for which she seeks class action status.

Meanwhile, drugmakers and members of Congress aim to change restrictions that prohibit Medicare from paying for weight-loss drugs.

The potential black swan? Even as all this insurance and supply drama plays out, we’re learning more and more about the potential risks of semaglutide and because no one took it. that long term, it is still possible that we will discover terrible long-term effects.

Learn more about semaglutide: Walmart Spys on Ozempic Patients’ Shopping Habits, Finds They’re Buying Less Food