SSM Health Care Agrees to $1 Million Settlement Over Improperly Waived Pharmacy Copays

SSM Health Care has agreed to pay approximately $1 million to resolve allegations that its Saint Louis University Hospital pharmacy improperly waived patient copays, causing Medicare and the Federal Employees Health Benefits Program to overpay for prescriptions. The settlement, announced by the U.S. Attorney’s Office for the Eastern District of Missouri, resolves a qui tam whistleblower lawsuit filed in 2023.

The government alleged that from September 2020 through February 2023, employees of the retail pharmacy at SSM-SLUH, including the pharmacist-in-charge, routinely waived and failed to collect patient copays. Routine waivers of copays are improper because they are viewed as illegally inducing patients to use a specific pharmacy. They also misrepresent the actual cost of the prescription, resulting in Medicare and FEHBP paying inflated costs in violation of the False Claims Act. The settlement requires SSM to pay $939,290—double the amount of restitution owed—plus $150,000 in attorneys’ fees and costs to the whistleblower. The whistleblower will receive $159,210 as their share of the recovery. SSM fully cooperated in the investigation and took appropriate remedial action, and the settlement contains no admission of liability.

“Consistently failing to collect patient copays in any instance, other than a well-documented case of financial hardship, violates federal law and inflates the prescription costs that federal health care programs must pay,” said U.S. Attorney Thomas C. Albus. This case reflects the government’s commitment to ensuring that pharmacies do not use improper financial incentives that undermine fair competition and weaken federal program safeguards.