Drug Channels’ mid-April 2026 roundup highlights two structural shifts reshaping the U.S. drug channel. A Milliman paper commissioned by PhRMA explains how vertically integrated insurers manage medical loss ratio (MLR) requirements, those rules that mandate 80% to 85% of premiums go toward care, through internal accounting maneuvers. They overpay affiliated providers or hold rebate funds within parent companies, effectively moving profit from regulated insurance entities to unregulated affiliates. The same issue includes Drug Channels’ February analysis showing that by 2025, nearly 40% of commercially insured members were in plans using copay maximizers, which redirect manufacturer assistance from patients to payers and PBMs.
The collision of integration and benefit redesign shows how financial engineering, rather than clinical value, drives competition among the largest payers and PBM groups. When a parent company controls how “efficiencies flow through the business segments,” as Milliman put it, the boundary between patient benefit and corporate gain gets fuzzy. In theory, integrated models should lead to lower premiums. Yet Drug Channels found almost no evidence those savings reach consumers. If profits keep sitting outside regulated entities, regulators are going to notice. Probably sooner rather than later.
For plan sponsors and PBM clients, the growing reach of copay maximizers, touching about two in five commercial members last year, shows these programs are becoming standard, even as manufacturers push back harder. Heightened scrutiny of MLR accounting could push integrated insurers to change how they handle rebates and intercompany markups, reshaping their financial playbook. The next numbers worth tracking will be payer MLR disclosures and any CMS or state guidance on how vertical integration influences rebate treatment. Personally, I'd wager that once regulators start digging into the flow of funds, the tidy corporate structures won’t look quite so tidy.
