For years, much of the consternation around the vertical integration strategies of payers has focused on their moves in the provider space: CVS Health buying Oak Street Health, Humana buying Kindred at Home, and UnitedHealth Group (UHG) buying enough physician groups to be affiliated with at least 90K, or 10 percent of all US physicians. UHG’s care delivery ambitions are serious, but looking at the 2025 audited financial results for four of the largest publicly traded payers shows the real story of vertical integration does not run through providers. Humana, Cigna, CVS, and UHG all earn more revenue from their pharmacy than their provider businesses; Cigna and CVS even earn more from pharmacy than their insurance businesses. It is no coincidence that these four companies also operate the four largest pharmacy benefit managers (PBMs), controlling 87 percent of the market between them. PBMs are often accused of lacking transparency, and one reason for that is that the health insurers they contract with to manage drug benefits and split the manufacturers’ rebates with are often under the same parent company. Congress recently enacted some PBM reforms intended to reorient the PBM business model away from their worst practices, but as long as a conflict of interest exists between payers and PBMs, there will be a danger of savings intended for patients instead being retained by vertically integrated middlemen.