A class-action lawsuit filed against CVS Caremark in the Southern District of New York on Wednesday accuses the pharmacy benefit manager of unlawfully denying coverage for Zepbound, a popular GLP-1 weight loss drug from Eli Lilly, in favor of a competing product from Novo Nordisk.
The suit, brought under the Employee Retirement Income Security Act (ERISA), claims the decision violates standards for evaluating medical necessity in employer-sponsored health plans, potentially harming millions of patients by forcing switches to less suitable alternatives.
John Cole, a 58-year-old patient from Texas who has lost over 60 pounds on Zepbound, described the abrupt loss of coverage as devastating. “When I got [Zepbound], I tell everybody, it’s like a gift to be able to lose this weight and to feel so much better and spend time with the grandkids and be able to go on walks and move around the yard,” Cole said.
“Now, it’s something I shouldn’t have to be going through. They should (care) about my health and not take things away from me.” Cole reported gaining some weight back after his coverage ended in July, when CVS Caremark removed Zepbound from its most common formulary plan.
One of Cole’s doctors echoed the frustration in a letter supporting his appeal for continued coverage. “It is my professional opinion that the patient’s health problems all seem to be improving on Zepbound and we would be hesitant to switch medications when things are going well,” the doctor wrote.
The lawsuit alleges that CVS Caremark’s policy prioritizes profits from a partnership with Novo Nordisk, maker of Wegovy, over patient needs.
The suit seeks to restore Zepbound coverage and award equitable relief for affected plan members.
CVS Caremark, which manages prescription benefits for over 100 million people, defended the move as a cost-saving strategy. David Whitrap, vice president of external affairs for CVS Health, stated, “We’ll defend ourselves vigorously against those claims.”
“Our formulary strategy maintains clinically appropriate coverage while using competition to drive lower costs. By drawing upon our decades of expertise in making prescription drugs more affordable and accessible, we are confident that our formulary move means lower costs and better outcomes for consumers and our customers,” he added.
Whitrap noted that a medical exceptions process exists for “rare cases” where on-formulary options like Wegovy prove ineffective or cause harmful side effects.
Novo Nordisk’s executive medical director, Jason Brett, pushed back on claims of interchangeability between GLP-1 drugs. “The notion that all GLP-1s are the same and ‘interchangeable’ is not correct,” Brett said.
Endocrinologists have reported increased administrative burdens from the changes. Dr. Jody Dushay, an endocrinologist at Beth Israel Deaconess Medical Center and assistant professor of medicine at Harvard Medical School, said, “The majority of the switches have been OK; however, ‘OK’ means extra work for the pharmacist with whom I work and for me.”
“When the dosing is not right, people may gain weight or plateau for a month and get frustrated. I’m deliberately more conservative with dosing so that people don’t get slammed with side effects,” she said.
The case highlights growing tensions in the GLP-1 market, where drugs like Zepbound and Wegovy have transformed obesity treatment but face supply shortages and high costs exceeding $1,000 monthly without coverage.
Legal experts predict the lawsuit could influence how pharmacy benefit managers handle formularies amid booming demand for these medications.
But it is another sign of a healthcare and insurance system which is not working well for the benefit of patients.
No wonder that many Americans are now looking at alternatives, such as healthshare plans, as a way of taking greater control over their treatments.