GLP1s weight-loss drugs may soon be covered by health insurance under new Washington court ruling

May 10-A blanket refusal to cover weight-loss medication like GLP-1s is no longer allowed under Washington state law, an appeals court ruled last week.

Many health insurances do not provide coverage to weight-loss medication. In years past, weight-loss drugs have been ineffective and expensive with many side effects. That may be changing with the advent of GLP-1 medication like Ozempic, Wegovy or Manjaro.

Glucagon-like peptide-1 is a naturally occurring hormone within the body that regulates insulin uptake. The drug is injected and increases the amount of this hormone in the body.

First approved in 2005, the drug was primarily used for diabetes patients to increase and help regulate insulin in the body. The drug also suppresses appetite by slowing emptying of the stomach. The drug does not cause weight loss itself. Patients lose weight because the shot changes their eating habits by making them feel fuller.

With the advent of more effective weight-loss drugs, the new ruling from the Washington Court of Appeals forces insurances across the state to justify why they do not cover all drugs prescribed to lose weight.

The Washington statute "does not permit" a health insurance plan deciding "not to deal with a person's disability for no reason other than because it had always done so," wrote Judge Ian Birk in the May 4 ruling.

Under Washington law, obesity is considered a disability. A 2019 Washington Supreme Court ruling found that obesity is a protected disability, and employers cannot discriminate based upon the weight of employees. Along with anti-discrimination protections, a recognized disability comes with a range of other protections.

Last week's ruling does not end the lawsuit. While a general exclusion to weight-loss drugs is no longer permitted, a lower court will now decide whether health insurance had any reasonable justification for denying coverage in this case. Under the ruling health insurance may exclude coverage for a disability if the prescriptions are "experimental, not effective, or not cost effective," Birk wrote.

Plaintiff Jeannette Simonton sued her insurance when she discovered the company would not cover any medication to treat obesity.

In 2023, Simonton needed knee surgery, but she was required to lose weight first. The Ellensburg nurse had previously underwent bariatric surgery at a peak weight of 424 pounds. She fell to 250 pounds, but at a height of 5 -foot -2 , she was still considered medically obese. Her weight loss was not enough to OK the knee surgery, so her doctor prescribed her GLP1 medication. She lost an additional 80 pounds.

Simonton worked as a nurse for Kittitas Valley Healthcare in Ellensburg and received health care through the Washington State Health Care Authority. The Washington State Health Care Authority did not respond to a request for comment.

Any prescription drugs meant to treat obesity were not included in the plan even if the drugs were considered medically necessary. Simonton's bariatric surgery and nutrition counseling was covered by the insurance but not any prescription drugs, including GLP-1s.

That type of exclusion is still common among health insurances, according to University of Utah pharmacoeconomics professor Joey Mattingly.

"There is definitely a longstanding precedent around weight-loss drugs not being covered," Mattingly said. "When plans are deciding what to cover, they look at whether something is cosmetic or has a clinical purpose. Often weight-loss drugs were seen as ineffective and possibly even dangerous."

Mattingly believes these blanket exclusions for weight-loss drugs will go away in the coming years regardless of the court ruling.

"We are getting enough evidence for these drugs and prices are getting closer and closer to reasonable. It would not shock me at all if we got to a place where more employers started offering coverage for GLP-1s in their standard plan," he said.

Since that is not the case currently, Simonton has paid out-of-pocket for the obesity medication since 2023. That means $450 a month for the lowest dose of Manjaro. She is currently considering an increase to the dose and cost.

As a caregiver for her disabled husband, the financial cost of the drug has been a "heavy burden."

"Weight has always been my challenge, and financially it means I'm working an extra shift, I'm not putting money away for retirement or I can't pay off my house," Simonton said.

As a nurse she does not understand why effective weight-loss medication would not be covered by insurance when it was medically necessary for her to receive knee surgery.

"Obesity is a medical condition. It is a widespread epidemic in our country. Why can't we treat it? Why would you wait for somebody to get diabetes, get heart failure, have a heart attack? Let's prevent a problem before it becomes a big problem," she said.

In court, Simonton's lawyers have argued denying coverage only for the reason that prescriptions meant to treat obesity as discrimination of a disability recognized by Washington law.

A lower court dismissed the claims based on a state statute that allows for weight-loss drugs to be medicine that health plans are "not required to include." In the binding appeals court ruling, judge Ian Birk determined the regulation establishes a minimum benefit and does not address whether the exclusion is discriminatory.

Health insurance may not exclude that coverage "simply because they are to treat that disability."

"To do so would discriminate because of that disability," Birk wrote.

"What the statute does not permit ... is what Simonton and Kelso allege happened here - a plan's deciding not to deal with a person's disability for no reason other than because it had always done so," Birk wrote.

If other health insurances across the state drop loss blanket exclusions on weight-loss drugs, premiums could increase, according to Mattingly.

"The more benefits you get, the more premiums will be. Because the cost of health care gets divvied up amongst everyone in the plan," Mattingly said. "That's not a bad thing. But it all depends on what health care we most value in America."

The ruling is also not limited to weight-loss medications. Other blanket exclusions may be on the chopping block too. While the court case is about an exclusion of weight-loss medication, the ruling applies to any disability recognized by Washington.

According to Northwest Health Law Advocates director Emily Brice, the law could impact similar exclusions to hearing aids, mental health care and other areas.

"This ruling goes beyond obesity. Insurers have used broad exclusions to get out of providing coverage to many people with disabilities. This will impact every disabled person who has been denied care in Washington," she said.

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