CVS Caremark sued for dropping coverage of sleep apnea drug

Plaintiffs are going to court to challenge CVS Caremark’s decision to stop covering Zepbound, a weight-loss drug that is also used to treat sleep apnea.

Plaintiff Martin Hamburger filed his lawsuit in the U.S. District Court for the District of Columbia, alleging violations of the Employee Retirement Income Security Act. Excluding coverage for Zepbound violates ERISA and the terms of the health benefit plans they administer, Hamburger claims.

Hamburger suffers from “moderate obstructive sleep apnea,” diagnosed in 2015, his lawsuit stated.

“CVS Caremark failed to ‘take into account’ that obstructive sleep apnea is a covered medical condition under the Plan and that Zepbound is the only [Food and Drug Administration] approved medication for obstructive sleep apnea,” the lawsuit said.

Earlier this year, CVS Caremark removed Zepbound from its list of preferred medications after signing a rebate agreement with Wegovy maker Novo Nordisk A/S.

A second lawsuit was filed last month in New York. Both lawsuits say CVS Caremark violates health-care plan terms that generally require coverage for medically necessary drugs prescribed by doctors.

CVS Caremark did not respond to a request for comment.

The growth of weight-loss drugs – known as GLP-1s – have insurance companies scrambling to satisfy access while also absorbing the hefty costs.

‘Wrongfully denied benefits’

Hamburger endured surgeries as well as trying a continuous positive airway pressure (CPAP) machine, the lawsuit said, “which provided some relief but was not fully satisfactory.” Zepbound is a crucial medication for Hamburger to lead a normal life, the lawsuit said.

“Because of Defendants’ misconduct, Mr. Hamburger has been wrongfully denied benefits covered under the Plan and has been unable to begin his prescribed pharmaceutical treatment for obstructive sleep apnea,” the lawsuit added.

An Eli Lilly drug, Zepbound was first approved by the FDA for obesity in November 2023. On Dec. 20, 2024, the FDA approved Zepbound as the first and only prescription medicine for adults with moderate-to-severe obstructive sleep apnea and obesity

Eli Lilly executives touted the approval in a news release.

“Nearly half of clinical trial patients saw such improvements that they no longer had symptoms associated with [sleep apnea], marking a critical step forward in reducing the burden of this disease and its interconnected health challenges," said Patrik Jonsson, executive vice president, and president of Lilly Cardiometabolic Health and Lilly USA.

Hamburger’s lawsuit requests class-action status and various remedies, including an order declaring that CVS Caremark’s coverage decisions on Zepbound “violate ERISA and its ERISA-based fiduciary duties.”

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InsuranceNewsNet Senior Editor John Hilton has covered business and other beats in more than 20 years of daily journalism. John may be reached at [email protected]. Follow him on Twitter @INNJohnH.