A District of Columbia federal judge dismissed a lawsuit, proposed as a class action, June 10 that challenged denials of Zepbound to treat obstructive sleep apnea.
The lawsuit, filed by Martin Hamburger, alleged denials by the pharmacy benefit manager CVS Caremark on behalf of CareFirst BlueCross BlueShield violated the Employee Retirement Income Security Act. However, the judge found the plan’s explicit exclusion of “prescription drugs for weight loss” applied to Zepbound because the drug treats sleep apnea by promoting weight loss.
“[Mr.] Hamburger can pay for Zepbound himself or lobby his employer to renegotiate the terms of the group contract, but he cannot use ERISA to force CareFirst to pay for a drug it specifically excluded in its agreement with his employer,” the decision said.
“We are pleased with the ruling,” a CVS spokesperson said in a June 11 statement shared with Becker’s. “The decision reinforces the critically important role ERISA plays in providing employers with the flexibility to offer high-quality, customized and affordable coverage options to their enrollees and dependents.”
A similar case involving Elevance Health is still ongoing. Like this one, the lawsuit against Elevance also lists obstructive sleep apnea as a covered medical condition under the health plan.
Becker’s contacted CareFirst and will update this story if more information becomes available.
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