In theory, healthcare brings together a diverse set of stakeholders: providers, payers, pharmacy benefit managers (PBMs), and pharmacies, each playing a distinct role under different pressures and financial incentives.
Increasingly, many of those stakeholders belong to the same organization. A payer may own a PBM, or a PBM may own a specialty pharmacy. A health system may employ a prescriber and own the specialty pharmacy dispensing the medication.
Vertical integration isn’t necessarily good or bad. It can remove handoffs, consolidate accountability, and fund clinical services that standalone pharmacies struggle to sustain. But as roles converge, it becomes harder to see where the rules of the market end and participation in that market begins. The most useful question is not who should be permitted to own a specialty pharmacy, but whether a given arrangement is sufficiently transparent so patients, prescribers, and plan sponsors can understand how access decisions are made.
When PBMs own specialty pharmacies
PBM ownership draws the most attention, largely because of the breadth of the PBM role. PBMs administer prescription drug coverage on behalf of health plans and employers, which includes decisions about which drugs are covered, which pharmacies are in network, and how pharmacies are reimbursed.
The largest PBMs also own specialty pharmacies that dispense many of those prescriptions. Those pharmacies have substantial clinical and dispensing operations. They are accredited, staffed by specialty-trained pharmacists and nurses, deeply experienced in limited-distribution therapies, and, in many cases, operating the infrastructure that makes complex therapies available at national scale.
The structural tension and regulatory attention arises from the fact that one organization influences both the terms of participation and its own participation. A 2025 interim staff report by the Federal Trade Commission examined specialty generic drugs and reported that the three largest PBMs substantially marked up many of them at their affiliated pharmacies, and reimbursed affiliated pharmacies at higher rates than unaffiliated pharmacies for nearly all of the drugs reviewed.
PBMs have contested those conclusions. Their central arguments are that the report examines a narrow slice of the drug spend, that it does not account for rebates and total net cost to plan sponsors, and that PBM negotiating leverage lowers overall pharmacy spend in ways a per-drug margin analysis will not capture.
With the underlying question of transparency unsettled, legislators continue to discuss regulatory measures. In May 2026, the Patients Before Monopolies Act, which would prohibit common ownership of PBMs and pharmacies and require affected organizations to divest their pharmacy businesses, was reintroduced in Congress and remains pending. At the state level, Arkansas enacted a PBM pharmacy-ownership ban in 2025 that a federal court preliminarily blocked, and Tennessee enacted a similar law in May 2026 that is now being challenged.
When health systems own specialty pharmacies
Health systems are expanding into specialty pharmacy at pace. Hospitals and health systems accounted for 28% of accredited specialty pharmacy locations at the end of 2025, up from 15% in 2017. Including physician practices and other providers, provider-operated pharmacies represent roughly four in ten accredited locations.
Health system ownership brings a different kind of advantage: the pharmacy sits inside the care team and inside the medical record. For therapies that require coordinating prior authorization, benefits investigation, financial assistance, and ongoing monitoring, that proximity can shorten time to therapy and reduce the number of hands a case passes through.
It also carries its own incentives. Health systems benefit financially from retaining prescriptions and can act on that. Some self-insured systems require employees to use the system’s specialty pharmacy. Large systems use their scale and negotiating leverage to expand access for their own pharmacies.
The structural difference is one of scope rather than motive. A health system can promote and recommend its own pharmacy, but it generally does not determine which competing pharmacies are covered under a patient’s benefit.
Where the friction actually shows up
Both models create incentives to keep prescriptions in-house. Both are capable of excellent clinical care. What matters to patients is what happens when the two models point in different directions.
Consider a patient starting a complex specialty therapy whose care team already includes health-system pharmacists managing their monitoring and financial assistance. If the PBM requires that prescription to be filled at a pharmacy outside of the health-system, the transition may be entirely seamless. Or it may introduce a handoff at exactly the moment continuity matters most.
Sometimes a network requirement reflects a genuine clinical or contractual reality, such as a limited distribution agreement that leaves only one dispensing channel available. Sometimes it reflects benefit design set without visibility into the patient’s existing care relationships. From the patient’s chair, and often from the prescriber’s, those two situations look identical. That opacity, more than ownership itself, is what generates much of the frustration in this system.
Looking beyond the ownership debate
Prohibiting particular organizations from owning specialty pharmacies is a blunt instrument, and unlikely to improve patient care on its own. The more durable answer is transparency: making it clear how access decisions are made, who makes them, and on what basis, so that every party in the chain can evaluate whether the outcome serves the patient.
That points policymakers and healthcare leaders toward a practical set of questions: How is access to a given specialty drug determined, and by whom? How are patients directed to a pharmacy, and is that direction visible to the prescriber? Are the financial relationships behind that direction disclosed? Can the same standard of care coordination be achieved without narrowing patient choice?
As specialty therapies grow more complex, Cinnamon works toward timely, coordinated medication access to life-changing therapies while preserving transparency and meaningful choice, regardless of which pharmacy ultimately dispenses. Get in touch to discuss how Cinnamon can open new doors for your organization.
