In an ongoing investigation into the pricing practices of pharmacy benefit managers (PBMs), the Federal Trade Commission (FTC) plans to sue three of the largest PBMs - UnitedHealth Group's OptumRx, Cigna Group's Express Scripts, and CVS Health's Caremark. The FTC's report alleges that these companies have been driving up the prices of medications, including insulin, while steering customers away from cheaper alternatives. The report claims that PBMs use tactics such as ranking drugs on lists or formularies to influence customer choices. Some PBMs have been accused of excluding cheaper medications from formularies in exchange for larger rebates from drugmakers. The investigation was initiated in 2022, and the FTC has requested records and information about the business practices of six PBMs. Rising medication costs have led to about 30% of Americans rationing or skipping doses of their prescriptions. PBMs handle prescription drug benefits for health insurance firms and larger employers and have faced increased scrutiny from lawmakers and regulators [dfce12cb].
This development comes after OptumRx, one of the PBMs under investigation, reached a $20 million settlement with the U.S. Department of Justice (DOJ) to resolve allegations of improperly filling opioid prescriptions in combination with other drugs. The settlement was announced on June 27, 2024. The DOJ alleged that OptumRx violated the Controlled Substances Act by failing to properly monitor and report suspicious orders of opioids. OptumRx agreed to pay the settlement to resolve the claims [91b5390f].
Additionally, the U.S. Justice Department recently charged nearly 200 people, including doctors, nurses, and other healthcare professionals, with participating in healthcare fraud schemes worth $2.7 billion. The charges were announced by Attorney General Merrick Garland on June 28, 2024. The fraud schemes targeted various aspects of the healthcare system, including telemedicine, prescription drugs, and durable medical equipment. The investigations were led by the Justice Department's criminal fraud unit and involved the coordination of multiple federal agencies, including the FBI, DEA, and HHS-OIG. The charges are part of ongoing efforts to combat healthcare fraud and protect the integrity of the healthcare system [477fe8b3] [5b42e7a6].
Furthermore, the government has seized over $231 million in cash, luxury vehicles, gold, and other assets as part of the crackdown on healthcare fraud schemes [5a3a3b98].
The FTC's lawsuit against the three PBMs is another step in the ongoing efforts to address rising drug prices and ensure fair competition in the pharmaceutical industry. The outcome of the lawsuit could have significant implications for the pricing practices of PBMs and the accessibility of medications for consumers [dfce12cb].