UnitedHealth Group

In September 2024, the U.S. Federal Trade Commission filed an administrative complaint against UnitedHealth Group's pharmacy benefit manager Optum Rx, along with CVS Caremark and Cigna's Express Scripts, alleging that the three dominant PBMs used anticompetitive and unfair rebate practices that artificially inflated insulin list prices, restricted access to lower-list-price insulin products and shifted costs onto vulnerable patients. The FTC said the three companies collectively administer approximately 80% of all prescriptions in the United States, giving them enormous influence over which medications are included on health-plan formularies and the prices patients ultimately face. Federal Trade Commission – FTC sues Optum Rx, Caremark and Express Scripts over insulin practices: https://www.ftc.gov/news-events/news/press-releases/2024/09/ftc-sues-prescription-drug-middlemen-artificially-inflating-insulin-drug-prices FTC – Insulin PBM case and proceeding: https://www.ftc.gov/legal-library/browse/cases-proceedings/221-0114-caremark-rx-zinc-health-services-et-al-matter-insulin According to the FTC complaint, Optum Rx and the other PBMs created a system in which their financial incentives favored drugs carrying high list prices and large manufacturer rebates. PBMs negotiate rebates with drug manufacturers and determine which medicines receive preferred placement on formularies used by health plans. The FTC alleged that this created what it described as a “chase-the-rebate” strategy: manufacturers had an incentive to increase insulin list prices so they could provide larger rebates and fees in exchange for favorable formulary placement. The FTC alleged that insulin list prices increased dramatically as this system developed. For example, the agency said the list price of Eli Lilly's Humalog increased from approximately $21 in 1999 to more than $274 by 2017, an increase exceeding 1,200%. The FTC did not attribute that entire increase solely to Optum Rx and specifically noted that insulin manufacturers also played a potentially culpable role in increasing prices. The FTC further alleged that even when manufacturers introduced lower-list-price insulin products, Optum Rx and the other PBMs systematically excluded some of those products from heavily used commercial formularies in favor of essentially equivalent products carrying higher list prices and larger rebates. FTC – Public administrative complaint: https://www.ftc.gov/system/files/ftc_gov/pdf/612314.2024.11.26_part_3_administrative_complaint_-_revised_public_redacted_version.pdf The alleged system was particularly harmful to patients whose deductibles or coinsurance were calculated using the insulin's unreduced list price. While health plans and PBMs could benefit from manufacturer rebates, some patients did not receive those rebates directly at the pharmacy counter. The FTC alleged that certain patients therefore could pay more out of pocket for insulin than the entire net cost of the drug after rebates to the commercial payer. The agency alleged that the PBMs knew their rebate and formulary practices could produce this result but continued the practices. The FTC also pointed to the broader affordability consequences of rising insulin prices. According to the agency, by 2019 approximately one in four insulin patients was unable to afford the medication. Because insulin is medically necessary for people with certain forms of diabetes, the FTC argued that patients could not reasonably avoid the harm simply by deciding not to purchase the drug. Company response: Optum Rx has strongly disputed the FTC's allegations. In its formal answer to the complaint, Optum Rx denied that its conduct caused insulin to become unaffordable for its members and stated that nearly all of its clients' members have access to a broad range of insulin products for less than $35 per month. Optum Rx – Formal answer to FTC complaint: https://www.ftc.gov/system/files/ftc_gov/pdf/611919.2024.10.09_optum_rxs_answer_to_complaint_0.pdf Optum has also argued publicly that drug manufacturers set insulin list prices and that its pharmacy-benefit business works to negotiate discounts and lower medication costs. Before the FTC complaint, Optum Rx announced in 2023 that it was moving eight insulin products to the preferred tier of its standard formularies, which it said would give consumers access to lower-cost options. Optum Rx – Actions to lower insulin costs: https://www.optum.com/en/newsroom/pharmacy-medications/optum-rx-takes-additional-steps-lower-cost-of-insulin.html Optum Rx has therefore not admitted the FTC's allegations, and the case should not be described as a finding that UnitedHealth or Optum illegally inflated insulin prices. There has also been an important recent development. The FTC reached settlements with Express Scripts in February 2026 and Caremark in July 2026 concerning the broader PBM case. On July 14, 2026, the FTC announced that its case against Optum had been withdrawn from adjudication so the Commission could consider a proposed consent agreement. As of August 2026, this means the Optum matter is moving toward a possible negotiated resolution, but the proposed agreement should not yet be described as a final Optum settlement. FTC – July 2026 update on Optum and PBM settlements: https://www.ftc.gov/news-events/news/press-releases/2026/07/ftc-secures-major-settlement-caremark-resolving-antitrust-case-against-second-drug-middleman Key facts: The FTC brought the case against UnitedHealth Group's Optum Rx in September 2024; Optum Rx was one of the three dominant PBMs accused of unfair and anticompetitive insulin rebate practices; the three PBMs collectively administer approximately 80% of U.S. prescriptions; the FTC alleges that their rebate structures favored high-list-price, highly rebated insulin and restricted access to lower-list-price alternatives; the FTC alleges that vulnerable patients sometimes paid more for insulin than the drug's entire net cost to the commercial payer after rebates; Optum Rx denies the allegations and says nearly all of its clients' members can access insulin for less than $35 per month; and in July 2026 the FTC withdrew the Optum case from adjudication while considering a proposed consent agreement. The case is significant for UnitedHealth Group because Optum Rx sits between drug manufacturers, health plans and patients and has substantial influence over formulary placement and pharmaceutical pricing incentives. However, unlike UnitedHealth's settled 2021 mental-health coverage case, the allegations against Optum Rx have not yet resulted in a final adverse finding or admission of wrongdoing. The evidence should therefore remain explicitly labelled as an FTC allegation unless and until the proposed Optum consent agreement becomes final.

In September 2024, the U.S. Federal Trade Commission filed an administrative complaint against UnitedHealth Group's pharmacy benefit manager Optum Rx, along with CVS Caremark and Cigna's Express Scripts, alleging that the three dominant PBMs used anticompetitive and unfair rebate practices that artificially inflated insulin list prices, restricted access to lower-list-price insulin products and shifted costs onto vulnerable patients. The FTC said the three companies collectively administer approximately 80% of all prescriptions in the United States, giving them enormous influence over which medications are included on health-plan formularies and the prices patients ultimately face. Federal Trade Commission – FTC sues Optum Rx, Caremark and Express Scripts over insulin practices: https://www.ftc.gov/news-events/news/press-releases/2024/09/ftc-sues-prescription-drug-middlemen-artificially-inflating-insulin-drug-prices FTC – Insulin PBM case and proceeding: https://www.ftc.gov/legal-library/browse/cases-proceedings/221-0114-caremark-rx-zinc-health-services-et-al-matter-insulin According to the FTC complaint, Optum Rx and the other PBMs created a system in which their financial incentives favored drugs carrying high list prices and large manufacturer rebates. PBMs negotiate rebates with drug manufacturers and determine which medicines receive preferred placement on formularies used by health plans. The FTC alleged that this created what it described as a “chase-the-rebate” strategy: manufacturers had an incentive to increase insulin list prices so they could provide larger rebates and fees in exchange for favorable formulary placement. The FTC alleged that insulin list prices increased dramatically as this system developed. For example, the agency said the list price of Eli Lilly's Humalog increased from approximately $21 in 1999 to more than $274 by 2017, an increase exceeding 1,200%. The FTC did not attribute that entire increase solely to Optum Rx and specifically noted that insulin manufacturers also played a potentially culpable role in increasing prices. The FTC further alleged that even when manufacturers introduced lower-list-price insulin products, Optum Rx and the other PBMs systematically excluded some of those products from heavily used commercial formularies in favor of essentially equivalent products carrying higher list prices and larger rebates. FTC – Public administrative complaint: https://www.ftc.gov/system/files/ftc_gov/pdf/612314.2024.11.26_part_3_administrative_complaint_-_revised_public_redacted_version.pdf The alleged system was particularly harmful to patients whose deductibles or coinsurance were calculated using the insulin's unreduced list price. While health plans and PBMs could benefit from manufacturer rebates, some patients did not receive those rebates directly at the pharmacy counter. The FTC alleged that certain patients therefore could pay more out of pocket for insulin than the entire net cost of the drug after rebates to the commercial payer. The agency alleged that the PBMs knew their rebate and formulary practices could produce this result but continued the practices. The FTC also pointed to the broader affordability consequences of rising insulin prices. According to the agency, by 2019 approximately one in four insulin patients was unable to afford the medication. Because insulin is medically necessary for people with certain forms of diabetes, the FTC argued that patients could not reasonably avoid the harm simply by deciding not to purchase the drug. Company response: Optum Rx has strongly disputed the FTC's allegations. In its formal answer to the complaint, Optum Rx denied that its conduct caused insulin to become unaffordable for its members and stated that nearly all of its clients' members have access to a broad range of insulin products for less than $35 per month. Optum Rx – Formal answer to FTC complaint: https://www.ftc.gov/system/files/ftc_gov/pdf/611919.2024.10.09_optum_rxs_answer_to_complaint_0.pdf Optum has also argued publicly that drug manufacturers set insulin list prices and that its pharmacy-benefit business works to negotiate discounts and lower medication costs. Before the FTC complaint, Optum Rx announced in 2023 that it was moving eight insulin products to the preferred tier of its standard formularies, which it said would give consumers access to lower-cost options. Optum Rx – Actions to lower insulin costs: https://www.optum.com/en/newsroom/pharmacy-medications/optum-rx-takes-additional-steps-lower-cost-of-insulin.html Optum Rx has therefore not admitted the FTC's allegations, and the case should not be described as a finding that UnitedHealth or Optum illegally inflated insulin prices. There has also been an important recent development. The FTC reached settlements with Express Scripts in February 2026 and Caremark in July 2026 concerning the broader PBM case. On July 14, 2026, the FTC announced that its case against Optum had been withdrawn from adjudication so the Commission could consider a proposed consent agreement. As of August 2026, this means the Optum matter is moving toward a possible negotiated resolution, but the proposed agreement should not yet be described as a final Optum settlement. FTC – July 2026 update on Optum and PBM settlements: https://www.ftc.gov/news-events/news/press-releases/2026/07/ftc-secures-major-settlement-caremark-resolving-antitrust-case-against-second-drug-middleman Key facts: The FTC brought the case against UnitedHealth Group's Optum Rx in September 2024; Optum Rx was one of the three dominant PBMs accused of unfair and anticompetitive insulin rebate practices; the three PBMs collectively administer approximately 80% of U.S. prescriptions; the FTC alleges that their rebate structures favored high-list-price, highly rebated insulin and restricted access to lower-list-price alternatives; the FTC alleges that vulnerable patients sometimes paid more for insulin than the drug's entire net cost to the commercial payer after rebates; Optum Rx denies the allegations and says nearly all of its clients' members can access insulin for less than $35 per month; and in July 2026 the FTC withdrew the Optum case from adjudication while considering a proposed consent agreement. The case is significant for UnitedHealth Group because Optum Rx sits between drug manufacturers, health plans and patients and has substantial influence over formulary placement and pharmaceutical pricing incentives. However, unlike UnitedHealth's settled 2021 mental-health coverage case, the allegations against Optum Rx have not yet resulted in a final adverse finding or admission of wrongdoing. The evidence should therefore remain explicitly labelled as an FTC allegation unless and until the proposed Optum consent agreement becomes final.

In August 2021, United Behavioral Health and UnitedHealthcare Insurance agreed to pay $15.6 million and take corrective action following investigations and litigation by the U.S. Department of Labor and the New York Attorney General. Federal investigators found that, going back to at least 2013, the companies reduced reimbursement rates for out-of-network mental-health services, causing patients to pay more for treatment. Investigators also found that patients receiving mental-health care were flagged for additional utilization reviews, resulting in many payment denials. Of the total, approximately $13.6 million was designated for affected patients and beneficiaries, with another roughly $2 million in penalties. Because this was a settlement following government investigations—not merely an unresolved private allegation—it is particularly strong evidence. U.S. Department of Labor documentation: https://www.dol.gov/newsroom/releases/ebsa/ebsa20210812

In August 2021, United Behavioral Health and UnitedHealthcare Insurance agreed to pay $15.6 million and take corrective action following investigations and litigation by the U.S. Department of Labor and the New York Attorney General. Federal investigators found that, going back to at least 2013, the companies reduced reimbursement rates for out-of-network mental-health services, causing patients to pay more for treatment. Investigators also found that patients receiving mental-health care were flagged for additional utilization reviews, resulting in many payment denials. Of the total, approximately $13.6 million was designated for affected patients and beneficiaries, with another roughly $2 million in penalties. Because this was a settlement following government investigations—not merely an unresolved private allegation—it is particularly strong evidence. U.S. Department of Labor documentation: https://www.dol.gov/newsroom/releases/ebsa/ebsa20210812

The U.S. Department of Justice is conducting a criminal and civil investigation into UnitedHealth Group's Medicare Advantage billing practices. The investigation is examining whether the company improperly submitted diagnoses that increased Medicare payments from the federal government. UnitedHealth has stated that it is cooperating with the investigation and has denied any wrongdoing. In July 2025, UnitedHealth publicly confirmed that it had received criminal and civil requests from the Department of Justice relating to its Medicare Advantage business. Company statement: https://www.unitedhealthgroup.com/newsroom/2025/2025-07-24-uhg-responds-to-doj-investigation.html Reuters: https://www.reuters.com/legal/litigation/unitedhealth-complies-with-doj-criminal-civil-requests-filing-shows-2025-07-24/ Wall Street Journal: https://www.wsj.com/health/healthcare/unitedhealth-medicare-doj-diagnosis-investigation-66b9f1db

In November 2023, a federal class action lawsuit was filed against UnitedHealth Group alleging that its subsidiary, UnitedHealthcare (through naviHealth), used the AI tool nH Predict to help make coverage decisions for Medicare Advantage patients receiving post-acute care. The plaintiffs allege that the system resulted in premature denials of medically necessary care and that the company continued using it despite concerns about its accuracy. UnitedHealth has denied the allegations, and the litigation is ongoing. News: https://www.statnews.com/2023/11/14/unitedhealth-class-action-lawsuit-algorithm-medicare-advantage/ Court case: Estate of Gene B. Lokken et al. v. UnitedHealth Group, Inc. et al., U.S. District Court, District of Minnesota, Case No. 23-cv-3514.