Zepbound Lawsuit Alleges CVS Caremark Wrongfully Denied Coverage for Medication as Sleep Apnea Treatment

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A consumer claims in a proposed class action lawsuit that CVS Caremark violated federal law and the terms of his health benefit plan when it denied him coverage for Zepbound, the only FDA-approved prescription medication for the treatment of obstructive sleep apnea.

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The 22-page lawsuit was filed against healthcare insurer Group Hospitalization and Medical Services, Inc., which does business as CareFirst BlueCross BlueShield, and CVS Caremark, the pharmacy benefit manager for CareFirst plans. The suit says that CVS Caremark denied the plaintiff’s claim on the basis that his plan did not cover Zepbound, even though the injectable weight management medication was prescribed by his healthcare provider to treat obstructive sleep apnea, a condition covered under the CareFirst plan.

According to the CVS Caremark lawsuit, the categorical exclusion of coverage for Zepbound as a sleep apnea treatment has violated claims procedure requirements established under the federal Employee Retirement Income Security Act (ERISA) and the terms of CareFirst plans, which promise to cover medications that are prescribed for treatment of qualifying conditions.

The case states that Zepbound was removed from the list of covered prescription medications on July 1, 2025, with the stipulation that excluded drugs would be covered if medically necessary. The complaint contends that although CareFirst left several “alternatives” to Zepbound on the coverage list, none of the remaining options are approved by the U.S. Food and Drug Administration (FDA) for obstructive sleep apnea treatment.

The plaintiff, a Washington, D.C., resident, says that CVS Caremark denied his pre-authorization request for Zepbound as a sleep apnea treatment on February 25, 2025 because his “prescription benefit plan [did] not cover the requested medication.”

The filing asserts that CVS Caremark’s claims procedure is deficient, and argues that the company failed to take into account that the consumer’s condition was covered under the plan and that Zepbound is the only approved medication for it.

The lawsuit alleges that CVS Caremark and CareFirst have fallen short of ERISA’s requirements by failing to ensure that eligibility determinations are made in accordance with health plan documents, and by failing to adequately notify the plaintiff of the specific reasons for the denial of his claim.

Moreover, the defendants failed to sufficiently evaluate an internal appeal submitted by the consumer in April 2025 and ignored his request to process the claim for Zepbound as a “non-formulary drug request,” the suit contends.

The case charges that as a result of CVS Caremark’s “mechanical denial” of coverage, the plaintiff has been deprived of his rightful benefits under the health plan and has paid out of pocket for an alternative medication to treat his sleep apnea.

The class action lawsuit looks to represent all current, former or future participants or beneficiaries covered under ERISA welfare benefit plans administered by CareFirst BlueCross BlueShield with pharmacy benefit management programs administered by CVS Caremark who, since December 20, 2024, required or will require Zepbound to treat obstructive sleep apnea.

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