The case of United States ex rel. Behnke v. CVS Caremark Corp., No. 14-cv-824 (E.D. Pa.), is a qui tam lawsuit filed in 2014 under the False Claims Act (FCA) in the U.S. District Court for the Eastern District of Pennsylvania. The case was initiated by whistleblower Sarah Behnke, a former head actuary for Medicare Part D at Aetna, against CVS Caremark Corporation, a major pharmacy benefit manager (PBM).
This case concerns the complex interplay between the Centers for Medicare and Medicaid Services (“CMS”), health insurers, pharmacy benefits managers (“PBMs”), and pharmacies. It involves health insurers Aetna and SilverScript, PBM Caremark, and pharmacies Walgreens, Rite Aid, and CVS Pharmacy.
Sarah Behnke, initiated this whistleblower case against CVS Caremark Corp. (including its pharmacy benefit manager subsidiary, CVS Caremark) for causing two Medicare Part D Plan Sponsors, Aetna and SilverScript, to report false and inflated drug prices for purchases made at three national chain pharmacies (Walgreens, Rite Aid, and CVS pharmacies), causing the federal government to overpay for these generic drugs.
Caremark argued that Medicare was aware that the actual costs of drugs dispensed to Medicare Part D beneficiaries were lower than the reported costs, but did nothing about it, and continued to pay claims based on the reporting. Therefore, Caremark argued, its alleged misconduct was not material to Medicare’s decision to continue to pay subsidies.
In its summary judgment decision on April 2, 2024, the United States District Court for the Eastern District of Pennsylvania granted partial summary judgment in favor of the whistleblower, ruling as a matter of law that some of the reported prices were false (leaving to the jury to decide whether additional reported prices also were false). The Court also rejected the CVS Health defendants’ attempt to have the claims dismissed without trial.
Three individuals intimately involved in Aetna’s internal investigation of Caremark’s pricing scheme testified at trial: Jean Walker, Sarah Behnke, and Charles Klippel along with other plaintiff and defense witnesses. After an eight-day non-jury trial in March 2025, Chief Judge Mitchell S. Goldberg of the U.S. District Court for the Eastern District of Pennsylvania issued a comprehensive 105 page Memorandum Opinion on June 25, 2025 indicating that CVS Caremark Corporation would be required to pay the U.S. government $95 million in actual damages.
The court found that CVS Caremark knowingly managed drug prices to maximize profits, leading to Medicare overpaying for prescription drugs. Although the court ruled in favor of CVS Caremark on some claims, it held them liable for the overcharges. Judge Goldberg will decide after further briefing whether to triple the damages to $285 million under the False Claims Act. Additionally, the court has not yet determined how many individual false claims were submitted, With mandatory civil penalties under the FCA, this could also increase the final judgment amount.
According to a review of this case by Duane Morris LLP, the ruling is notable since PBMs have rarely been named defendants in FCA cases. In controlling the flow of medications between drug manufacturers, health insurance companies and pharmacies, and ultimately to pharmacy customers, PBMs obviously yield a substantial amount of power within the drug-pricing space.
Medicare relies on PBMs providing accurate information and reporting in order to keep drug costs within reasonable ranges. This case demonstrates the consequences when these entities, which are historically meant to lower drug prices, actually illegally inflate them. It also speaks to the ability of the FCA to serve as a remedy when that trust is breached.
Third, this ruling sheds more light on the all-too-opaque process of drug pricing. In recent years, the federal government has taken action in an attempt to halt these pricing practices. Beginning in 2024, CMS banned direct and indirect renumeration fees, which previously allowed PBMs to claw back reimbursements remitted to pharmacies based on undisclosed metrics.
Just recently, attorneys from the U.S. Department of Health and Human Services and the U.S. Department of Justice announced the formation of a working group focused on enforcing the FCA. Priority areas for enforcement include Medicare Advantage and drug pricing, two areas in which PBMs and pharmacies are directly involved.
Two of the pharmacies allegedly involved in Caremark’s scheme include Rite-Aid and Walgreens. Rite-Aid recently filed for bankruptcy, and Walgreens is closing over 1,000 stores nationwide in response to financial difficulties.