Sounding The Alarm: Legal Action Against CVS Caremark’s Zepbound Denials

On July 1, CVS Caremark began forcing patients to switch from Zepbound to Wegovy – and we quickly took action to help folks fight back by appealing. With many patients protected by step therapy and non-medical switching laws, we were confident in their cases. The majority of these denials should have been overturned easily. 

They weren’t. 

Our team quickly started noticing an unusual – and troubling – pattern. Appeals were getting denied at a high rate and at unusual speed. Denials were coming back not in the standard hours or days, but in minutes – all following the same script and formula, returned with almost identical responses. Same wording. Same rationale. Same disregard for the patient’s actual medical needs.

Under federal law, every appeal is supposed to get a full, fair, individualized review by a human reviewer. These weren’t reviews. They were copy-paste auto-replies. This falls well outside of what we’ve been used to from insurers, and it raised serious legal concerns. 

Seeing the patterns in the data

The appeals process is typically fragmented, with individual patients and providers rarely compiling or comparing notes. Spotting trends is nearly impossible. But by handling hundreds of appeals specifically for CVS’s Zepbound forced-switch patients, Claimable had a unique vantage point. We saw systemic, policy-wide denials unfolding in real time. These weren’t a few isolated cases; we were seeing a consistent, repeated pattern of patients being denied their legal rights.

We immediately began supporting second-level appeals and escalation to independent review, including a detailed opinion from our Senior Legal Advisor, D. Brian Hufford, Esq., of The Hufford Law Firm PLLC, to help patients fight for the coverage they deserved.  More appeals began to succeed – but not nearly enough. 

Our success rate doubled after escalating cases with stronger legal arguments, but it remained below our usual benchmarks. That wasn’t good enough. We knew something was deeply wrong. So even while individual appeals were starting to work, it was clear that this broader pattern of systemic denials raised bigger legal questions – questions that went beyond what the appeals process alone can fix.

So with Brian, we began investigating additional options.

The CVS Caremark Zepbound lawsuit and your right to a full, fair, individualized review

Working closely with patients we’d supported through their appeals, Brian took the evidence to Berger Montague, a firm that specializes in healthcare class action litigation.

On September 3, 2025, they filed a class action lawsuit against CVS Caremark on behalf of patients in ERISA-governed employer-sponsored health plans whose coverage for Zepbound was denied and whose appeals were rejected based on medical necessity.

The lawsuit alleges that CVS Caremark wrongfully denied coverage by issuing denials that appeared to rely on templated language, despite patients meeting the plans’ criteria for medical necessity. Filed under ERISA, the suit alleges that CVS Caremark:

• Breached its fiduciary duties by prioritizing financial gain over medical appropriateness or plan obligations;

• Engaged in prohibited transactions by entering formulary agreements that benefit its own bottom line;

• Violated the terms of employer health plans by denying coverage for an FDA-approved, medically necessary treatment – while steering patients toward non-equivalent or off-label alternatives; and

• Ignored federal claims procedure standards by failing to provide timely, transparent, and individualized appeal reviews.

The complaint asks the court to issue injunctive relief, requiring CVS to change its policies going forward. It also seeks other appropriate equitable relief if those remedies are found insufficient to fully address the harm to patients. 

Advocacy doesn’t end with the appeal

Since July 1st, we’ve helped hundreds of patients file appeals for Zepbound denials. That’s only a tiny slice of the hundreds of thousands of patients affected. But it’s enough to spot the trend and push for accountability.

To be clear: Claimable isn’t a party to this suit. The relief it seeks isn’t on our behalf. But for us, being a patient-first company means taking a root cause approach to solving problems whenever possible. In this case, it meant going beyond the appeals process we operate within and connecting patients to legal options they might not otherwise access.

We built Claimable to make appealing easier and more successful. But just as importantly, we built it to expose what’s really happening behind the scenes. Denials don’t happen in isolation, and neither can our response.

That’s why we’re proud to support a broader movement for change, alongside legal teams, advocacy organizations, and policy leaders. Appeals are one piece. Litigation is another. Legislative reform is critical too. The only way to deter unjust denials is to challenge them—again and again—until insurers and pharmacy benefit managers face real consequences for saying no without cause.

What’s next for Zepbound appeals 

Legal action takes time, and we’ll be watching closely as this case makes its way through the courts. But while the system may be slow, we’re not slowing down. We will continue helping patients appeal these Zepbound forced switches – and we’ll keep evolving our strategies as new evidence and appeal precedents emerge.

We hope this lawsuit sends a clear message: insurer misconduct that puts patients at risk will not go unnoticed or unchallenged.

Our job isn’t just to make paperwork easier and arguments stronger. It’s to fight back when something feels wrong. To listen to patients. To advocate. To act.

And we won’t stop until everyone gets the care they need and coverage they deserve.