Amid a months-long shortage of semaglutide-based diabetes and weight loss drugs, one woman is suing her insurer for not covering the medication.
As the New York Times reports, Washington State nurse Jeannette Simonton was told that her insurer has a blanket ban on weight loss meds and would not cover her prescription for Wegovy, the semaglutide injectable that's swept off shelves this year.
So now she's suing the Washington State Health Care Authority — the agency responsible for purchasing public employee health insurance — for discrimination, arguing that obesity is a legally recognized disability in Washington and that insurance, therefore, must cover it. As such, it's a significant case for 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 diabetes sister 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 drug because of its ability to lower blood sugar levels, semaglutide for weight loss was approved by the Food and Drug Administration in 2021 after drug manufacturers found that it also helped patients feel fuller and eat less.
Over the past few years, Wegovy and Ozempic have become the stuff of headlines and memes as more and more people — already an estimated 1.7 percent of the total American population, or 5.68 million people — are prescribed the injectable that many users consider to be a revolution in weight management.
In spite of all those prescriptions, however, Wegovy and Ozempic are increasingly difficult to acquire due to an industrial shortage. And those lucky enough to find them in pharmacies are often forced to pay for the drug, which can run more than $1,000 per month, out-of-pocket because their insurers, like Simonton's, refuse to cover them.
"They’re being penny wise and pound foolish," the 57-year-old nurse told the NYT. "What will they be paying in 10, 15 years if I don’t continue to lose the weight?"
Simonton's argument is a common one: that the imposing cost of the medication, which has no generic, will ultimately save her and her insurer money because it will preclude obesity-related health issues.
She may be correct, but not all experts agree.
"These drugs are insanely expensive and desired by a ton of patients, and the patient can never get off them," James Gelfand, the president and CEO of the employer advocacy group ERISA Industry Committee, told Insider over the summer. "The drug companies, providers, and patient groups are insisting that weight loss will improve health and therefore offset these massive costs. That's not true."
Simonton ultimately decided to go to a compounding pharmacy to get an unauthorized GLP-1 agonist. Even that off-label version has had its cost, however: the nurse told the NYT that she's shelled out close to $2,000 out-of-pocket so far, and has had to dip into her retirement fund and even spend less on groceries to cover it.
In her suit against the state healthcare agency, Simonton is seeking to recoup the money she's already shelled out and force the state to pay for state employees' Wegovy prescriptions in the future, which she's seeking class-action status to do so.
In the meantime, drugmakers and members of Congress are aiming to change restrictions that bar Medicare from paying for weight loss medication.
The potential black swan? Even as all this insurance and supply drama plays out, we're learning more and more about semaglutide's potential risks — and because nobody has been taking it that long, it's always possible that we'll discover some terrible long-term effect.
More on semaglutide: Walmart Spies on Ozempic Patients' Shopping Habits, Finds They're Buying Less Food
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