Migliaccio & Rathod LLP is investigating whether certain employer-sponsored health plans may have improperly conditioned continued coverage of GLP-1 medications on patients achieving a specific weight-loss, BMI, or other health outcome.
Some employer health plans cover medications such as Wegovy or Zepbound only if the patient also participates in a weight-management program. We are particularly interested in plans that go further and tell patients that they must lose a particular percentage of their body weight, reach a particular BMI, or achieve another specified health result in order to continue receiving coverage for the medication.
Federal rules impose special requirements on certain employer health programs that condition a financial reward, penalty, or benefit on achieving a health-related result. Depending on how a GLP-1 program is structured, a plan that conditions continued prescription-drug coverage on achieving a particular weight-loss or health outcome may be required to provide patients with an alternative way of qualifying for the benefit.
We are investigating whether some plans terminated GLP-1 coverage when patients failed to reach these targets without providing an appropriate alternative or accommodating the recommendations of the patient’s physician.
You May Be Affected If:
- You receive health insurance through your private-sector employer, or through a spouse’s or parent’s private-sector employer;
- Your health plan covered a GLP-1 medication such as Wegovy or Zepbound for weight management;
- To keep coverage, you were required to lose a specific amount or percentage of weight, reach or maintain a particular BMI, or achieve another measurable health result;
- Your medication was denied or your coverage was discontinued because you did not achieve that result;
- You were not offered another reasonable way to maintain coverage;
- Your doctor believed the required goal was inappropriate for you, but the plan refused to accommodate your doctor’s recommendation; or
- You had to pay for the medication yourself, stop taking it, or switch treatments because your coverage was terminated.
We are especially interested in hearing from patients whose denial letter said they had failed to achieve a required percentage of weight loss.
Merely being required to enroll in a weight-management program, speak with a dietitian, attend coaching sessions, or use an app is not necessarily enough for this investigation. We are particularly interested in people whose continued medication coverage depended on actually achieving a specified health result.
Does This Apply to Your Health Plan?
This investigation generally concerns health plans obtained through a private-sector employer, including through a spouse’s or parent’s private-sector employment.
Both self-funded employer plans and plans insured through an insurance company may qualify. Government employee plans and certain church plans generally do not.
If you do not know whether your employer’s health plan is governed by ERISA, we can generally determine that from your insurance card, Explanation of Benefits, Summary Plan Description, denial letter, or other benefits documents.
We Are Interested in Hearing From Patients Who:
- had Wegovy, Zepbound, or another GLP-1 medication initially covered;
- were later told they had not lost enough weight to keep coverage;
- were required to hit a numerical weight-loss or BMI target;
- were denied continued coverage despite following their doctor’s treatment plan;
- asked for another way to qualify and were denied;
- had a physician recommend an accommodation that the plan refused;
- paid substantial amounts out of pocket after coverage ended; or
- stopped or changed treatment because they could no longer afford the medication.
If your employer-sponsored health plan stopped covering a GLP-1 medication because you did not meet a required weight-loss or health target, we would like to hear from you.
There is no charge to speak with us, and there is no obligation to take legal action.
Please complete the contact form on this page, send us an email at [email protected], or call us at (202) 470-3520.
Migliaccio & Rathod LLP is a Washington, D.C.-based law firm that represents consumers and employees in class-action litigation nationwide.