Obese Washington woman who lost 80lbs on Wegovy sues her health insurer for refusing to cover the $1,300-a-month weight-loss drug

A woman is suing her health insurance company for refusing to cover the weight-loss drug Wegovy that was prescribed by her doctor to treat her obesity. 

Jeannette Simonton, a nurse from Kittitas County, Washington, weighed 228 pounds when she was prescribed Wegovy by her doctor 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 the minimum for the medication. 

She was also suffering joint problems after decades of being overweight.

However, Ms Simonton was insured under Washington State Health Care Authority, health insurance provided by the state, which does not cover any obesity treatments.

Jeannette Simonton, a nurse from Kittitas County, Washington, was prescribed Wegovy by her doctor in February 2023. She is pictured here in a photo posted on Facebook in 2017

Since taking Wegovy, Ms Simonton has been able to get a knee replacement operation done

She began paying for her Wegovy prescription herself, which has cost her nearly $2,000, and lost 80 pounds on the drug. Following her weight loss, she was able to get a total knee replacement to address her joint pain. 

Ms Simonton said: ‘I feel amazing. I feel like I getting my life back. I’m a lot more active, I’m able to swim. I’ve started a lot more exercising. I’ve been able to get my first total knee done since then and that’s freed me up, so now I can actually go for walks.’

In March, however, her health insurance informed her the medication would not be covered, citing a blanket ban on weight-loss drugs. 

Finding this out was ‘so disappointing’, she said.

Dr Peter Billing, a bariatric and weight loss specialist doctor, told NewsNation that insurance companies should be covering the medication.

He said: ‘It’s discriminatory against people who are obese, and it’s totally wrong.

‘The thought is, people are obese because they’re lazy. They don’t cut down what they’re eating, 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 a disability or serious health condition. 

Under Washington state law, obesity is categorized as a disability and the lawsuit lawsuit argues the rejection of the coverage is an unlawful form of discrimination.

‘Today, health insurers have to base their decisions on whether the treatment is medically effective or not,’ Ms Simonton’s attorney, Ele Hamburger, explained.

‘The science here is so clear cut, that the only reason for continuing to exclude this kind of treatment for a recognized serious medical condition is discrimination. It’s discrimination on the basis of disability.’

After paying for her Wegovy prescription herself for several months, she sued the insurer in September, but admitted if she does not win the suit, she will continue to pay for it herself and will not stop taking it.

Demand for Wegovy and other appetite-suppressant drugs has skyrocketed.

But with 42 percent of American adults who are obese, insurance companies are reluctant to cover the huge price tag. The list price for a month’s supply of Wegovy in the US is $1,349 per patient, while the similar drug Ozempic costs $936.

Only some private insurers cover drugs like Wegovy and Ozempic, but some federal and state insurance programs like 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, though it is prescribed off-label for weight loss.

Most private insurance companies cover some or all of the cost of the drugs when they are prescribed for type 2 diabetes, but they are not usually covered for weight loss. 

According to a benefits consultant cited by the Associated Press, less than half of employers’ health insurance plans cover obesity drugs.