Mapping the Vertical Integration of Insurers, PBMs, GPOs, Specialty Pharmacies, and Healthcare Services: DCI’s 2026 Update

It's time for Drug Channels Institute’s (DCI) annual update of vertical integration among insurers, PBMs, specialty pharmacies, and healthcare services within U.S. drug channels. As you can see below, we have updated and revised our infamous illustration of the major vertical business relationships within the largest companies.

These organizations continue to exert greater control over patient access, sites of care/dispensing, and pricing, although some have started to unwind their vertical integration strategies. Scrutiny of these companies’ actions continues to grow.

For all the details behind these companies’ operations, check out DCI’s new 2026 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers.

The chart below provides an updated illustration of the major vertical business relationships among insurers, PBMs, specialty pharmacies, healthcare services, and other companies within U.S. drug channels. The companies are listed alphabetically by insurer name.

[Click to Enlarge]

This chart appears as Exhibit 267 in the 2026 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers.

Section 12.3.1. of the report reviews the transactions that created these companies and explains the incentives for—and potential competitive challenges from—vertical integration. Throughout the 2026 report, we analyze the various businesses within these organizations:

• Pharmacy benefit managers (Section 5.2.2.)

• Retail pharmacies (Section 2.3.3.)

• Specialty pharmacies (Section 3.3.2.)

• Group purchasing organizations (Section 5.2.4.)

• Private label products (Section 5.2.5.)

• Healthcare providers (Section 1.4.1.)

Here are some notable changes from last year’s edition:

• Affiliated third-party administrators (TPAs) and administrative services only (ASO) platforms are included within the “Insurer” category. Most large employers self-fund their health benefits and contract with these affiliated ASO/TPA platforms for claims administration and network access. Although these entities do not assume underwriting risk, they serve as the primary gateway to employer-sponsored lives and can channel volume to vertically integrated subsidiaries.

• Businesses that work with hospitals and health systems to provide specialty pharmacy services are included within specialty pharmacy. Health systems and hospitals have emerged as the fastest-growing direct participants in the specialty pharmacy market by operating internal pharmacies. They account for nearly one-third of all specialty pharmacy locations accredited by ACHC or URAC. Changes in manufacturers’ 340B contract pharmacy policies have accelerated hospitals’ investments in in-house specialty pharmacy operations.
  
  As we discussed in last month’s news roundup, The Cigna Group’s Evernorth Health Services now owns 100% of CarepathRx, which assists hospitals and health systems with specialty pharmacy operations. In 2025, Evernorth also invested $3.5 billion for an undisclosed stake in Shields Health Solutions, the former Walgreens Boots Alliance subsidiary with a similar hospital-focused specialty pharmacy model.
  
  In 2024, UnitedHealth Group acquired CPS Solutions, which also offers specialty pharmacy services to hospitals and health systems.

• Businesses that have been sold off have been removed. For example, Centene began outsourcing PBM operations to Express Scripts in 2024. It has also sold various other businesses, including the Magellan Rx PBM, PANTHERx Rare specialty pharmacy, the Magellan Specialty Health benefit management company, and a majority stake in its U.S. Medical Management physician home health business. In 2025, Cigna quietly sold its Evernorth Care Group, which had operated 18 primary care clinics, to HonorHealth.

As vertical integration evolves—and in some cases unwinds—these interconnections remain essential to understanding how drugs flow through the channel, where profits accumulate, and how we all experience the U.S. healthcare system.

We’ll be back in 2027 with another update— assuming the industry or Congress doesn’t reorganize everything first.