An Anthem Blue Cross subscriber is suing the health insurer, alleging she was wrongfully denied coverage for Zepbound for weight management because she was no longer considered morbidly obese.
Alicia Butterfield’s Los Angeles Superior Court lawsuit alleges breach of contract and of the implied covenant of good faith and fair dealing. She seeks unspecified compensatory and punitive damages.
An Anthem representative did not immediately reply to a request for comment.
According to her complaint, prior to becoming covered by Anthem, Butterfield was a Blue Shield member and in 2022 the insurer approved coverage of the drug Mounjaro to treat her then-morbid obesity. At the time, she had a body-mass index higher than 40 as well as conditions of pre-diabetes and high blood pressure, the suit states.
Butterfield switched to an Anthem HMO plan on Feb. 1 of this year and her doctors asked that Anthem cover Mounjaro as well, the suit states. The insurer declined because she did not have diabetes, but suggested her physicians request Zepbound instead, the suit states.
Butterfield needed to remain on tirzepatide, the compound for Mounjaro and Zepbound, in order to maintain her weight loss, the suit states.
However, on April 15 Anthem sent a letter to Butterfield denying the Zepbound request, stating that her plan only provides coverage for morbid obesity while not even mentioning the company’s alleged prior suggestion that she seek a prescription for the weight loss drug, according to the suit.
Butterfield filed a grievance with Anthem over its decision that was denied, the complaint states.
Anthem knew that its alleged wrongful rejection of weight loss drugs for patients previously diagnosed as morbidly obese with comorbidities made it highly likely that those people would begin gaining weight and suffer from the return or aggravation of their comorbidities, the suit alleges.
“Despite this knowledge, Anthem intentionally and wrongfully refused Zepbound for Alicia simply because the drug began to work for her and lowered her weight to where she was no longer morbidly obese…,” according to the suit.
Anthem’s wrongful rejection of Butterfield’s Zepbound request has caused a worsening of her medical condition, the suit alleges.