It’s time for the Drug Channel Institute’s (DCI) annual update on vertical integration between payers, PBMs, specialty pharmacies, and healthcare services within the U.S. drug channel. As seen below, we have updated and revised the infamous diagram of key vertical business relationships within the largest companies.
Although these organizations continue to maintain greater control over patient access, points of care/dispensing, and pricing, some have begun to loosen their vertical integration strategies. The actions of these companies continue to come under increasing scrutiny.
For all the details behind the operations of these companies, check out DCI’s new report. 2026 Economic Report on U.S. Pharmacy and Pharmacy Benefit Managers.
The chart below provides an updated picture of the key vertical business relationships between payers, PBMs, specialty pharmacies, healthcare services, and other companies within the U.S. pharmaceutical channel. Companies are listed alphabetically by insurance company name.
[Click to Enlarge]
This chart is published as Exhibit 267. 2026 Economic Report on U.S. Pharmacy and Pharmacy Benefit Managers.
Section 12.3.1. The report reviews the deals that created these companies and discusses the incentives for vertical integration and the potential competitive challenges of vertical integration. Throughout the 2026 report, we analyze various businesses within these organizations.
- Pharmacy Benefits Manager (Section 5.2.2.)
- Retail Pharmacy (Section 2.3.3.)
- Specialty Pharmacy (Section 3.3.2.)
- Group Purchasing Organizations (Section 5.2.4.)
- Private Label Products (Section 5.2.5.)
- Healthcare Providers (Section 1.4.1.)
Notable changes from last year’s edition include:
- Related Third Party Administrator (TPA) and Administered Services Only (ASO) platforms are included in the “Insurer” category. Most large employers self-fund their medical benefits and contract with these affiliated ASO/TPA platforms for claims management and network access. These entities carry no underwriting risk, but can serve as the primary gateway to employer-assisted living and direct funds to vertically integrated subsidiaries.
- Specialty pharmacies include companies that work with hospitals and health systems to provide specialty pharmacy services. Health systems and hospitals are the fastest growing direct participants in the specialty pharmacy market by operating in-house pharmacies. They account for nearly one-third of all specialty pharmacy locations accredited by ACHC or URAC. Changes in manufacturers’ 340B contract pharmacy policies are accelerating hospitals’ investment in in-house specialty pharmacy operations.
As explained in last month’s news roundup, Cigna Group’s Evernorth Health Services now owns 100% of CarepathRx, which helps hospitals and health systems run specialty pharmacy operations. In 2025, Evernorth also invested $3.5 billion in private equity in Seals Health Solutions, a former Walgreens Boots Alliance subsidiary with a similar hospital-focused specialty pharmacy model.
In 2024, UnitedHealth Group acquired CPS Solutions. CPS Solutions also provides specialty pharmacy services to hospitals and health systems.
- Sold businesses have been removed. For example, Centene began outsourcing its PBM operations to Express Scripts in 2024. We also sold various other businesses, including Magellan Rx PBM, PANTHERx Rare specialty pharmacy, Magellan Specialty Health benefits management company, and a majority stake in our American Healthcare Management Physician Home Health business. In 2025, Cigna quietly sold Evernorth Care Group, which operated 18 primary care clinics, to HonorHealth.
Even as vertical integration evolves and, in some cases, eases, these interconnections remain essential to understanding how medicines flow through channels, where profits accumulate, and how we all experience the U.S. health care system.
There will be another update in 2027, assuming the industry and Congress don’t reorganize everything first.
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