The exclusion - not medical necessity - decided it, and the wording did all the work
Employers wondering whether they must cover costly GLP-1 drugs just got a clear answer from a federal court: the plan's fine print rules.
On June 10, 2026, a judge in Washington dismissed a lawsuit by a worker who wanted his employer's health plan to pay for Zepbound, a GLP-1 medication used for weight loss and sleep apnea. For HR and benefits teams, the ruling is a timely, concrete look at how coverage exclusions hold up when a member pushes back.
Martin Hamburger gets his coverage through a plan sponsored by his employer, Destination DC, a tourism nonprofit in the District of Columbia. CareFirst BlueCross BlueShield administers the plan, with CaremarkPCS Health acting as its pharmacy benefit manager - the company that manages which prescription claims get paid.
Hamburger has obstructive sleep apnea, in which the airway becomes blocked during sleep. His doctor prescribed Zepbound after the FDA approved it in December 2024 to treat moderate-to-severe sleep apnea in adults with obesity, alongside a reduced-calorie diet and more activity. When the coverage request came in, Caremark denied it, saying the plan does not cover the drug and that the decision involved no medical judgment. Hamburger's attorney appealed. Caremark did not budge.
He then sued under ERISA, the federal law governing employee benefit plans, with two claims: wrongful denial of benefits and breach of fiduciary duty. He also sought to represent a class of similarly situated members.
The court tossed all of it - and the reason was the plan document. The prescription drug rider excludes coverage for "Prescription Drugs for weight loss." Because CareFirst's own formulary, its list of covered drugs, labels Zepbound an "anti-obesity agent[]," the judge found it fell within the exclusion.
Hamburger argued the FDA's sleep-apnea approval made Zepbound something other than a weight-loss drug. The court was unmoved, noting the FDA cleared it for sleep apnea because it reduces body weight. He also flagged that the plan covers Mounjaro, a "chemically identical" drug, for diabetes. That did not move the needle either, since Mounjaro is approved for diabetes regardless of a patient's weight.
The fiduciary-duty claim fared no better. Administrators who follow a plan as written, the court said, are not breaching their duty - and the claim simply repeated the benefits claim, which most courts say bars it.
For HR leaders, the lesson is unusually plain. The case did not hinge on medical necessity or sympathy. It hinged on wording. The court stressed that ERISA plans must be read as written and as a whole, exclusions and all. With GLP-1 requests piling up, the decision is a reminder that coverage scope lives in the plan language - and that changing it is a plan-design choice for the employer, not a courtroom outcome.
