Insurance won’t cover Ozempic? WA court sparks discrimination debate

Washington Court of Appeals this month revived a legal fight against health insurers' blanket refusals to cover weight loss medications like Ozempic and Wegovy.

In a decision published May 4, the court ruled that insurance plans that prohibit certain types of obesity treatment could potentially violate state antidiscrimination law.

Over the past few years, weight loss medications known as GLP-1 drugs have exploded in popularity. The drugs are approved by the Food and Drug Administration for the treatment of obesity among other conditions. But they're also expensive, and many health plans don't cover them if prescribed solely for weight loss use.

As a result, people prescribed GLP-1 drugs for obesity often have to pay hundreds of dollars per month out of pocket. Those who can't often turn to compounded versions of the drugs, or go without.

Last week's ruling tees up a potential legal battle that could eventually strike down blanket bans on weight loss drug coverage in Washington. Such a conclusion — though far from assured — could make the pricey blockbuster medications widely affordable and accessible.

The recent ruling stems from a lawsuit filed by Ellensburg resident Jeannette Simonton in 2023.

That year, Simonton's doctor prescribed her a GLP-1 drug to help treat her obesity. Specifically, she needed to lose 40 pounds before she could get knee surgery.

Then a nurse at a public hospital, Simonton got insurance through the Washington State Health Care Authority, which administers plans for state employees.

The healthcare authority denied her GLP-1 drug coverage, leaving her to pay for it on her own. Simonton then sued.

The authority did not respond to a request for comment.

The lawsuit I filed because as a nurse I was very upset at people not having access to this medication," Simonton said in a phone interview. She grew frustrated as she learned that colleagues and patients were refused coverage for weight loss drugs just as she was. "I fought with weight my entire life, and it's been a struggle."

The case was dismissed in trial court in 2024, so her attorneys filed an appeal. The recent appellate case ruling says that insurers cannot exclude coverage for medical treatments solely based on the fact that they address obesity.

"What this says is you cannot, when you design a health insurance plan, pick out a disability and exclude coverage for that disability," said Rick Spoonemore, one of Simonton's attorneys. "So you can't say, as these plans did, 'We're not going to provide coverage for obesity or we're not going to provide coverage for drugs for obesity.'"

The ruling did not find that weight loss drug coverage bans are discriminatory — only that they could be. It also does not mandate that health insurance plans cover weight loss drugs.

For now, the ruling simply kicks the case back to trial court, where insurers will have the opportunity to argue that their weight loss drug coverage bans are not discriminatory. They can do so by proving that GLP-1 drugs are not medically necessary or clinically effective, or that their cost outweighs their benefits.

But making such a case could be an uphill battle, Spoonemore said. "That's a tough burden because the science right now for the GLP-1s is so incredibly strong."

Central to the appellate court ruling are Washington's disability protections, which are broader in scope than the federal equivalent. Under the Washington Law Against Discrimination, obesity is a covered disability, the state Supreme Court ruled in 2019. That's not the case in most other states or at the national level.

Back in trial court, the plaintiffs will seek class certification, allowing the suit to move forward as class action, Spoonemore said. The case could also get taken up by the state Supreme Court.

The lawyer estimated that a trial would take up to a year to play out in either case.

In the meantime, Simonton is still paying out of pocket for her weight loss medication, which costs around $450 a month. That's on top of her monthly insurance premium of $500 per month. She feels confident that her case is strong.

"It's not just about me, it's about everybody, patients and people who need access to these kinds of medication.

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