By Jeffrey H. Brochin, J.D.
Settlement reached in FCA lawsuit against CVS Pharmacy, Inc. (CVS) that alleged that Code 1 prescriptions were filled without proper diagnoses or documentation resulting in the drugs’ reimbursement claims being in violation of both the federal FCA and California’s FCA.
The United States Attorney’s Office for the Eastern District of California has announced that settlement has been reached in a False Claims Act (FCA) lawsuit brought by a Relator who alleged that CVS violated the federal FCA and the California False Claims Act when it knowingly submitted claims for reimbursement for certain prescribed medications to California’s Medi-Cal program that were not supported by applicable diagnosis and documentation requirements. As part of the settlement, CVS agreed to pay the total sum of $18,282,280.08, apportioned between the United States and California. The settlement agreement (Agreement) further provided for the Relator to received approximately $3.3 million of the recovery proceeds (Settlement Agreement, U.S. ex rel. Zimniski v. CVS Health Corporation, No. 2:19-cv-1118 (E.D. Cal. Nov. 17, 2025)).
Code 1 prescription requirements. The Complaint alleged that between January 1, 2010, and April 30, 2021, CVS knowingly and falsely certified and submitted for reimbursement through the electronic claims submission and reimbursement process claims for prescription drugs, identified with a “*” on the Medi-Cal List of Contract Drugs (Code 1 drugs),...
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