govinfo:USCOURTS-dcd-1_25-cv-03000-0

UNITED STATES DISTRICT COURT 
FOR THE DISTRICT OF COLUMBIA 
 
MARTIN HAMBURGER, 
 
Plaintiff, 
 
v. 
 
CAREFIRST BLUECROSS 
BLUESHIELD, et al., 
 
Defendants. 
 
 
 
 
Case No. 1:25-cv-03000 (TNM) 
 
MEMORANDUM OPINION 
 
 Recent years have seen the meteoric rise of GLP-1 drugs. Originally developed for 
diabetes, these drugs also ameliorate obesity—prompting a surge in demand. Martin Hamburger 
is one of the many people who have turned to these medications. His doctor prescribed him 
Zepbound after the Food and Drug Administration (“FDA”) approved the drug for treating 
obstructive sleep apnea in overweight people. Hamburger wants his health insurer to cover the 
drug, but it refuses to do so. To challenge this reimbursement denial, Hamburger sues—both for 
himself and on behalf of a putative class—under the Employee Retirement Income Security Act 
(“ERISA”). He advances claims for denial of benefits and breach of fiduciary duty. Neither 
survives dismissal. Because Hamburger’s health plan excludes Zepbound and Hamburger has 
not plausibly alleged any breach of fiduciary duty, his lawsuit cannot proceed. 
I. 
 Hamburger participates in a health plan sponsored by Destination DC , a tourism non-
profit in the District of Columbia. Group Contr., ECF No. 1-1, at 4;1 see About Destination DC, 
 
1 All page numbers refer to the pagination generated by CM/ECF. 

2 
https://washington.org/dc-information/about-destination-dc [https://perma.cc/D3YH-HZT5]. 
The plan is governed by a Group Contract between Destination DC and CareFirst BlueCross 
BlueShield (“CareFirst”). Group Contr. at 4. As the plan’s administrator, CareFirst enlists 
CaremarkPCS Health (“Caremark”) as a “pharmacy benefit manager” to manage claims for 
prescription drug benefits. Compl., ECF No. 1, ¶ 31. 
 Hamburger has obstructive sleep apnea—a “sleep disorder in which an individual’s upper 
airway becomes blocked while asleep.” Id. ¶¶ 16, 34. To treat that condition, his doctor 
prescribed Zepbound. Id. ¶ 20. Zepbound activates hormones secreted from the intestine, 
including glucagon-like peptide-1 (GLP-1), to reduce appetite. See What is Zepbound, Eli Lilly, 
https://tinyurl.com/37e4af5n [https://perma.cc/WEM5-EQYY]. Recognizing that obstructive 
sleep apnea “is more common in people who [are] overweight or obes[e]” and that Zepbound 
“reduc[es] body weight,” the FDA approved Zepbound “for the treatment of moderate to severe 
obstructive sleep apnea . . . in adults with obesity, to be used in combination with a reduced-
calorie diet and increased physical activity.” FDA Approves First Medication for Obstructive 
Sleep Apnea, U.S. Food and Drug Admin. (Dec. 20, 2024) (“FDA Approval”), 
https://www.fda.gov/news-events/press-announcements/fda-approves-first-medication-
obstructive-sleep-apnea [https://perma.cc/CN3G-GPYQ]. 
 Hamburger wants his health insurer to pay for Zepbound. So, his doctor submitted a 
coverage request to CareFirst. Compl. ¶¶ 44–45. Acting as pharmacy benefit manager, 
Caremark denied the request. Id. ¶ 46. The denial letter stated that Hamburger’s “prescription 
benefit plan does not cover the requested medication.” Initial Adverse Determination Notice, 
ECF No. 1-2, at 2. Caremark further explained that “[t]his decision relate[d] specifically to 

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coverage provided under [Hamburger’s] prescription benefit plan and d[id] not involve any 
determination of medical judgment.” Id. 
 Undeterred, Hamburger ’s attorney appealed the denial. Compl. ¶ 51; see Internal Appeal 
Letter, ECF No. 1-3, at 2–4. Caremark did not budge. In another denial letter, it repeated that 
Hamburger’s “pharmacy benefit plan does not cover Zepbound,” referring him “to the 
prescription benefit drug section in [his] Explanation of Coverage document.” Final Adverse 
Determination Notice, ECF No. 1-4, at 2. 
 With no other internal recourse, Hamburger sued CareFirst and Caremark here. His 
Complaint advances two ERISA claims—one for denial of benefits under 29 U.S.C. 
§ 1132(a)(1)(B), the other for breach of fiduciary duty under 29 U.S.C. § 1132(a)(3). Compl. 
¶¶ 78–92. Hamburger also seeks to certify a class of all “participants or beneficiaries covered 
under ERISA welfare benefit plans administered by [CareFirst] with pharmacy benefit 
management programs administered by [Caremark]” who “required or will require Zepbound for 
the purpose of treating obstructive sleep apnea.” Id. ¶ 70. CareFirst and Caremark each moved 
to dismiss the Complaint, and their motions are now ripe. See ECF Nos. 19, 23. 
II. 
In addressing a motion to dismiss under Rule 12(b)(6), the Court must determine whether 
the plaintiff “state[s] a claim to relief that is plausible on its face.” Ashcroft v. Iqbal, 556 U.S. 
662, 678 (2009) (cleaned up); see Fed. R. Civ. P. 12(b)(6). The Court must “treat the 
complaint’s factual allegations as true and must grant the plaintiff[] the benefit of all inferences 
that can be derived from the facts alleged.” Xia v. Tillerson, 865 F.3d 643, 649 (D.C. Cir. 2017) 
(cleaned up). But the Court need not credit “legal conclusions cast in the form of factual 
allegations.” Kowal v. MCI Commc’ns Corp., 16 F.3d 1271, 1276 (D.C. Cir. 1994). Assessing 

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whether a claim survives dismissal is a “context-specific task that requires the reviewing court to 
draw on its judicial experience and common sense.” Robinson v. Howard Univ., Inc., 335 F. 
Supp. 3d 13, 21 (D.D.C. 2018) (quoting Iqbal, 556 U.S. at 679), aff’d sub nom., Robinson v. 
Wutoh, 788 F. App’x 738 (D.C. Cir. 2019). 
Aside from the complaint, the Court may also consider “documents incorporated into the 
complaint by reference, and matters of which a court may take judicial notice.” Tellabs, Inc. v. 
Makor Issues & Rts., Ltd., 551 U.S. 308, 322 (2007). So too for “those portions of documents 
upon which the plaintiff’s complaint necessarily relies even if the document is produced not by 
the plaintiff in the complaint but by the defendant in a motion to dismiss.” Page v. Comey, 137 
F.4th 806, 814 (D.C. Cir. 2025) (cleaned up). 
III. 
Hamburger cannot maintain either his benefits or fiduciary-duty claim. The dismissal of 
his individual claims also dooms his putative class action. The Court addresses each in order. 
A. 
Hamburger asserts that Defendants are liable under ERISA for refusing to pay for 
Zepbound even though his health plan entitles him to reimbursement. Compl. ¶¶ 78–81. That 
claim’s downfall is its false premise: Rather than covering Zepbound, the Group Contract 
excludes it. 
ERISA authorizes an individual “to recover benefits due to him under the terms of his 
plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits 
under the terms of the plan.” 29 U.S.C. § 1132(a)(1)(B). “That statutory language speaks of 
enforcing the terms of the plan, not of changing them.” Heimeshoff v. Hartford Life & Accident 

5 
Ins. Co., 571 U.S. 99, 108 (2013) (cleaned up). Because Hamburger’s claim depends on the 
Group Contract, the Court walks through that document’s key provisions. 
The Group Contract or “Evidence of Coverage” is “th[e] agreement, which includes any 
attachments, amendments and riders, if any, between [Destination DC] and CareFirst.” Group 
Contr. at 9. The parties’ dispute centers on the “Prescription Drug Benefits Rider” that amends 
the Group Contract. Id. at 152–62. The Rider “contains specific exclusions and limitations 
applicable to Prescription Drug benefits that are in addition to the exclusions contained in the 
Evidence of Coverage.” Id. at 152. The Rider’s exclusions also apply to CareFirst’s formulary, 
which lists the drugs CareFirst covers subject to a member’s plan. See id. at 153. When 
Hamburger sought coverage, Zepbound was included on CareFirst’s formulary among the “anti-
obesity agents.” See CareFirst Formulary 3, ECF No. 19-1, at 4–5; see also Compl. ¶¶ 39–40 
(discussing Zepbound’s inclusion on CareFirst Formulary 3). 
Hamburger’s argument rests on one provision from the Rider. See Compl. ¶ 36. It states 
that “benefits will be provided for a Prescription Drug dispensed by a Pharmacist for self-
administered-use on an outpatient basis for the treatment of a condition for which benefits are 
provided under the terms of the Evidence of Coverage.” Group Contr. at 155. The Rider defines 
“Prescription Drug” as “[a] drug, biological, product or compounded prescription intended for 
outpatient use that carries the FDA legend ‘may not be dispended without a prescription.’” Id. at 
154. Without any further contractual anchor, Hamburger contends that “[o]bstructive sleep 
apnea is a covered medical condition under the Plan” and that he thus is entitled to coverage for 
Zepbound in treating it. See Compl. ¶ 35. So far, so good. 
 But the Rider foils Hamburger’s bid only a few pages later. The “Exclusions” section 
disclaims coverage for 15 categories of products, including “[r]outine immunizations and 

6 
boosters” and most vitamins. Group Contr. at 161–62. Most unfortunate for Hamburger is 
exclusion 13, which states that “[b]enefits will not be provided” for “Prescription Drugs for 
weight loss.” Id. That exclusion applies to Zepbound, a GLP-1 drug that CareFirst’s formulary 
designated as an “anti-obesity agent[].” CareFirst Formulary 3 at 4–5. By its own terms, the 
Group Contract thus defeats Hamburger’s claim for benefits. See Stewart v. Nat’l Educ. Ass’n, 
471 F.3d 169, 175 (D.C. Cir. 2006) (affirming dismissal where plaintiff could not “escape the 
plain language in the Plan Document and Group Contract that show[ed] that he ha[d] not stated a 
claim for denial of benefits under 29 U.S.C. § 1132(a)(1)(B)”). 
 Hamburger wants the Court to put on blinders . He zeroes in on the Rider’s generic grant 
of prescription drugs for covered conditions. Compl. ¶ 36; see Group Contr. at 155. But even if 
obstructive sleep apnea counts as a covered condition, Hamburger’s argument is still too myopic. 
Ignoring the exclusions would flout a “cardinal principle of contract construction: that a 
document should be read to give effect to all its provisions and to render them consistent with 
each other.” See Mastrobuono v. Shearson Lehman Hutton, Inc., 514 U.S. 52, 63 (1995); see 
also Antonin Scalia & Brian A. Garner, Reading Law: The Interpretation of Legal Texts 167 
(2012) (“The text must be construed as a whole.”). That maxim rings especially true for ERISA, 
which requires benefits plans to “be enforced as written.” See M & G Polymers USA, LLC v. 
Tackett, 574 U.S. 427, 435 (2015) (cleaned up); see also Wright v. Metro. Life Ins., 618 F. Supp. 
2d 43, 57 (D.D.C. 2009) (emphasizing that “the Court cannot read into the Plan coverage where 
none exists”). Read as a whole, the Group Contract carves out weight loss drugs like Zepbound. 
 Tacitly recognizing the exclusion’s force, Hamburger tries to recast Zepbound as 
something other than a weight-loss drug. He reasons that the “FDA’s authorization of Zepbound 
to treat obstructive sleep apnea is a separate and distinct indication from its original approval as 

7 
an anti-obesity medication.” Pl.’s Opp’n, ECF No. 25, at 18. But the FDA’s authorization hurts 
him more than it helps. Recall that the FDA approved Zepbound for obstructive sleep apnea 
only “in adults with obesity, to be used in combination with a reduced-calorie diet and increased 
physical activity.” FDA Approval, supra Part I. That decision flowed from the agency’s finding 
that “[b]y reducing body weight, . . . Zepbound also improves” obstructive sleep apnea. Id. In 
other words, Zepbound helps with sleep apnea because it promotes weight loss, not as a separate, 
unrelated benefit. If anything, then, the FDA’s approval confirms that Zepbound is a weight-loss 
drug. 
 Hamburger does not stop there. He points out that “CareFirst covers GLP-1 medications 
that treat diabetes”—even Mounjaro, which is “chemically identical” to Zepbound. Pl.’s Opp’n 
at 19. To Hamburger, this signals that the “decision to exclude all coverage of Zepbound to treat 
obstructive sleep apnea is plausibly in violation of the Plan terms.” Id. at 19–20. But that does 
not follow. Mounjaro, after all, is FDA-approved only for treating diabetes—whether or not the 
person is also obese. See FDA Indications for Mounjaro at 1, U.S. Food and Drug Admin., 
https://www.accessdata.fda.gov/drugsatfda_docs/label/2026/215866s009lbl.pdf# 
[https://perma.cc/T5DD-GNSV]. Hamburger’s attempt to equate Zepbound with Mounjaro fails. 
 More broadly, Hamburger conflates direct and indirect effects. To understand how, 
consider one adjacent example. Studies have suggested that obesity amplifies the risk of 
depression. See 9 Frequently Asked Questions About Obesity and Depression, HealthLine, 
https://www.healthline.com/health/depression/obesity-and-depression [https://perma.cc/XWR3-
EG4S]. By combating obesity, GLP-1 drugs like Zepbound thus might indirectly alleviate 
depression. But that secondary consequence does not make Zepbound an antidepressant. Much 

8 
less does it mean that Zepbound is not a weight-loss drug. Hamburger’s argument would 
demand both inferences. Neither holds up. 
* * * 
Because Zepbound is a weight-loss drug, the Group Contract excluded it from coverage. 
Hamburger’s benefits claim cannot stand. 
B. 
Turn to Hamburger’s other claim, which invokes 29 U.S.C. § 1132(a)(3). Compl. ¶¶ 82–
92. That provision authorizes suits “to enjoin any act or practice which violates any provision of 
this subchapter or the terms of the plan, or . . . to obtain other appropriate equitable relief.” 29 
U.S.C. § 1132(a)(3). Section 1132(a)(3) is a “catchall” or “safety net, offering appropriate 
equitable relief for injuries caused by violations that [§ 1132] does not elsewhere adequately 
remedy.” Varity Corp. v. Howe, 516 U.S. 489, 512 (1996). The Varity Court “expect[ed] that 
where Congress elsewhere provided adequate relief for a beneficiary’s injury, there w[ould] 
likely be no need for further equitable relief, in which case such relief normally would not be 
‘appropriate’” under § 1132(a)(3). Id. at 515. 
“[T]he great majority of circuit courts have interpreted Varity to hold that a claimant 
whose injury creates a cause of action under § 1132(a)(1)(B) may not proceed with a claim under 
§ 1132(a)(3).” Korotynska v. Metro. Life Ins. Co., 474 F.3d 101, 106 (4th Cir. 2006) (Wilkinson, 
J.) (collecting cases). Although the D.C. Circuit has not weighed in, judges in this district have 
“followed the view of the majority of circuits that a breach of fiduciary [duty] claim under 
§ 1132(a)(3) cannot stand when a plaintiff has an adequate remedy for her injuries under 
§ 1132(a)(1)(B).” Zalduondo v. Aetna Life Ins. Co., 845 F. Supp. 2d 146, 155 (D.D.C. 2012); 

9 
accord Clark v. Feder Semo & Bard, P.C., 527 F. Supp. 2d 112, 116–17 (D.D.C. 2007); Wright, 
618 F. Supp. 2d at 56. 
This Court agrees. The “commonplace [canon] of statutory construction that the specific 
governs the general” shows why. See RadLAX Gateway Hotel, LLC v. Amalgamated Bank, 566 
U.S. 639, 645 (2012) (cleaned up). That canon cautions against reading general provisions in a 
manner that would “swallow[]” more specific ones. Id.; see also Scalia & Garner, supra Part 
III.A, at 174 (stating that no provision “should needlessly be given an interpretation that causes it 
to duplicate another provision”). It applies particularly when “Congress has enacted a 
comprehensive scheme and has deliberately targeted specific problems with specific solutions.” 
RadLAX Gateway Hotel, 566 U.S. at 645 (cleaned up). Allowing benefits claims under 
§ 1132(a)(1)(B) and “catchall” claims under § 1132(a)(3) to proceed in tandem would defy this 
canon and misread ERISA. 
Swimming with the stream of authority, the Court thus holds that Hamburger cannot 
advance his § 1132(a)(3) claim. That claim seeks to recover for the same underlying injury: the 
denial of coverage for Zepbound. See Compl. ¶¶ 78–92. “Because the gravamen of 
[Hamburger’s] complaint is that []he was improperly denied benefits, the remedies under 
[§ 1132(a)(1)(B)] would make [him] whole if []he were to prevail on h[is] claim.” See Clark, 
527 F. Supp. 2d at 117. Hamburger “does not allege harm to [him]self from [Defendants’] 
apparently isolated administrative errors or omissions . . . that is separable from the harm flowing 
from the allegedly improper denial of benefits.” See Zalduondo, 845 F. Supp. 2d at 155. 
“[B]ecause awarding [Hamburger] relief under § 1132(a)(1)(B) would fully redress his alleged 
injury, any claim [he] is making for equitable relief under § 1132(a)(3) is precluded.” See 
Wright, 618 F. Supp. 2d at 56. In short, ERISA forbids Hamburger’s attempt to double dip. 

10 
More, and in any event, Hamburger has not stated a plausible breach of fiduciary duty. 
None of his theories work. 
Hamburger tries to locate a breach in “Defendants’ categorical denial of Zepbound and 
failure to process requests for Zepbound to treat a covered medical condition.” Compl. ¶ 89. 
That claim is misplaced. Recall that the coverage denial adhered to the Group Contract’s terms. 
Supra Part III.A. Defendants did not breach their fiduciary duty in doing what Hamburger’s 
health plan demanded. See Heimeshoff, 571 U.S. at 108 (highlighting “the particular importance 
of enforcing plan terms as written”). Given the Group Contract’s categorical exclusion, 
Defendants also had no obligation to respond to Hamburger’s claims of “medical necessity.” See 
Compl. ¶ 90. They instead were on firm contractual ground in explaining that their denial “d[id] 
not involve any determination of medical judgment.” See Initial Adverse Determination Notice 
at 2. 
Nor is there merit to Hamburger’s claim that “Caremark failed to consider the Plan’s 
procedure for Non-Formulary Exception Requests when reviewing Mr. Hamburger’s internal 
appeal.” See Compl. ¶ 63. After all, Zepbound was on the relevant formulary at the time, see 
CareFirst Formulary 3 at 5—a fact that Hamburger concedes both in his Complaint and briefing, 
see Compl. ¶¶ 39–40; Pl.’s Opp’n at 10. Hamburger’s last-ditch assertion that “Zepbound was 
on the formulary in name only” fails to persuade. See Pl.’s Opp’n at 10. Common sense 
compels that Defendants had no duty to consider a non-formulary exception for a drug that was 
on the formulary. 
Lastly, Hamburger complains that Defendants failed to give him “adequate notice” in 
denying his coverage request. Compl. ¶¶ 87, 91. That claim, too, is unsuccessful. 

11 
ERISA requires benefit plans to “provide adequate notice in writing to any participant or 
beneficiary whose claim for benefits under the plan has been denied, setting forth the specific 
reasons for such denial.” 29 U.S.C. § 1133(1); see also 29 C.F.R. § 2560.503-1(g)(1) (requiring 
the denial notice to provide “[t]he specific reason or reasons for the adverse determination” and 
“[r]eference to the specific plan provisions on which the determination is based”). “Along with 
[its] sister circuits, [the D.C. Circuit] ha[s] adopted the ‘substantial compliance’ test to determine 
whether denial notices comply with section 1133 and the regulation.” White v. Aetna Life Ins. 
Co., 210 F.3d 412, 414 (D.C. Cir. 2000) (cleaned up). Under that standard, “[t]echnical 
noncompliance will be excused as long as the notice substantially complies with the statute and 
regulation.” Id.; accord, e.g., James v. Int’l Painters & Allied Trades Indus. Pension Plan, 844 
F. Supp. 2d 131, 152 (D.D.C. 2012), aff’d, 738 F.3d 282 (D.C. Cir. 2013) (per curiam). 
These denial notices pass the test. To recap, Caremark’s initial letter explained that 
Hamburger’s “prescription benefit plan does not cover the requested medication.” Initial 
Adverse Determination Notice at 2. In its response to Hamburger’s appeal, Caremark reiterated 
that his “pharmacy benefit plan does not cover Zepbound,” pointing him “to the prescription 
benefit drug section in [his] Explanation of Coverage document.” Final Adverse Determination 
Notice at 2. While terse, these communications articulated the reason for the denial and its basis 
in Hamburger’s health plan. Nothing more was needed. See White, 210 F.3d at 414. 
 In sum, because Hamburger’s § 1132(a)(3) claim is duplicative and implausible, it fails 
twice over. 
C. 
 That leaves one loose end. Recall that Hamburger’s aims surpass his own plight. He also 
sues on behalf of a putative class comprising “participants or beneficiaries covered under ERISA 

12 
welfare benefit plans administered by [CareFirst] with pharmacy benefit management programs 
administered by [Caremark]” who “required or will require Zepbound for the purpose of treating 
obstructive sleep apnea.” Compl. ¶ 70. This putative class action perishes along with 
Hamburger’s individual suit. 
 Rule 23(a) sets forth the “[p]rerequisites” for successful class actions. See Fed. R. Civ. P. 
23(a). Next to the elements of numerosity, commonality, and typicality, id. 23(a)(1)–(3), the 
Rule also demands that “the representative part[y] will fairly and adequately protect the interests 
of the class,” id. 23(a)(4). It is on this fourth requirement that Hamburger’s putative class action 
founders. “Since [Hamburger] himself has failed to state a viable claim against [D]efendant[s], 
he cannot act as the class representative or fairly and adequately protect the interests of the 
class.” See Rivera v. Rosenberg & Assocs., LLC, 142 F. Supp. 3d 149, 162 (D.D.C. 2015) 
(cleaned up); see also E. Tex. Motor Freight Sys. Inc. v. Rodriguez, 431 U.S. 395, 403–04 (1977) 
(holding that plaintiffs whose individual claims failed “were not proper class representatives” 
under Rule 23(a)); Gur-Ravantab v. Georgetown Univ., 345 F.R.D. 1, 7 (D.D.C. 2023) (denying 
class certification where named plaintiff was not a member of proposed class). As goes 
Hamburger’s individual suit, so does the class action. 
IV. 
Neither of Hamburger’s ERISA claims survives. Nor does his putative class action. The 
Court will thus grant Defendants’ motions to dismiss. A separate Order will issue. 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. 
 
Dated: June 10, 2026 TREVOR N. M cFADDEN, U.S.D.J. 

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