Washington Court Considers Health Insurer Coverage for Weight Loss Drugs
The Washington Court of Appeals has recently reignited a legal debate regarding health insurers' denials of coverage for weight loss medications, specifically those like Ozempic and Wegovy. The court's decision, published on May 4, suggests that insurance plans excluding certain obesity treatments may violate state antidiscrimination laws.
In recent years, GLP-1 drugs, which have received FDA approval for obesity treatment among other uses, have surged in popularity. However, their high cost has led many health insurance providers to decline coverage when prescribed solely for weight loss, causing individuals relying on these medications to face substantial out-of-pocket expenses.
The court ruling could lead to a significant legal contest, potentially overturning these coverage exclusions in Washington. Although not guaranteed, this development could expand access and affordability for these high-demand medications.
The case originates from a lawsuit filed by Jeannette Simonton, a resident of Ellensburg, in 2023. Her physician prescribed a GLP-1 drug to assist with weight loss required for knee surgery. As a state employee insured through the Washington State Health Care Authority, she was denied coverage and had to self-fund the medication, leading Simonton to file a lawsuit.
According to Rick Spoonemore, Simonton's attorney, insurers are now challenged to justify the exclusion of obesity-related treatments from their coverage designs. He remarked, "You cannot ... pick out a disability and exclude coverage for that disability."
The ruling does not declare these drug coverage bans discriminatory per se; however, it opens the possibility for such a determination. It also does not currently obligate insurers to cover weight loss drugs. The case returns to a trial court, where insurers will need to argue the medical necessity and cost-effectiveness of their current coverage policies.
The appellate court's decision is based on Washington’s comprehensive disability protections, recognized as more inclusive than federal standards. A 2019 state Supreme Court ruling acknowledges obesity as a covered disability under the Washington Law Against Discrimination. Looking forward, the plaintiffs seek to achieve class certification to proceed as a class action lawsuit, possibly reaching the state Supreme Court. Spoonemore anticipates a one-year timeline for the trial. Meanwhile, Simonton continues to cover the $450 monthly cost for her medication in addition to her insurance premiums, remaining hopeful about the case's broader implications for patient access.