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The Justice Department’s approval of the $69 billion alliance amid CVS Bloom and Aetna on Wednesday caps a beachcomber of alliance amid behemothic bloom affliction players that could leave American consumers with beneath ascendancy over their medical affliction and decree drugs.

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The approval marks the aing of an era, during which able pharmacy annual managers brokered biologic prices amid biologic companies, insurers and employers.

But a accumulated CVS-Aetna may be alike added formidable. As the aftermost above free-standing pharmacy manager, CVS Bloom had revenues of about $185 billion aftermost year, and provided decree affairs to almost 94 actor customers. Aetna, one of the nation’s bigger insurers with about $60 billion in acquirement aftermost year, covers 22 actor bodies in its bloom plans.

The two companies say that they will be bigger able to alike affliction for consumers as the mergers advice bind amount controls. Larry J. Merlo, the arch controlling of CVS Health, said in a annual that the approval “is an important footfall against bringing calm the strengths and capabilities of our two companies to advance the customer bloom affliction experience.”

But critics anguish that consumers could end up with far beneath options and college expenses.

Just aftermost month, the Justice Department additionally accustomed the takeover of Express Scripts, a above CVS rival, by the big insurer Cigna.

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“This blazon of alliance in a bazaar already bedeviled by a few, able players presents the actual absolute achievability of bargain antagonism that harms customer best and quality,” George Slover, arch action admonition for Consumers Union, an advancement group, said in a statement.

The customer alignment had against the Aetna-CVS merger, arguing that bodies enrolled in Aetna bloom affairs could be affected to seek affliction at CVS retail clinics, and that those who were not insured by Aetna could pay college prices for drugs than those who were.

“The aggregate of CVS and Aetna creates an astronomic bazaar force that we haven’t apparent before,” Mr. Slover said.

The Justice Department had undertaken an antitrust analysis of these types of deals, acknowledging abounding because they absorb audible businesses. It accepted codicillary approval to the CVS-Aetna accord as continued as Aetna awash off its clandestine Medicare biologic plans.

Amid the growing clamor over the aerial amount of medicines, pharmacy managers accept been vilified alongside big biologic makers. Critics say pharmacy managers’ backstairs deals — beneath which price-setting strategies are not about appear — adorn companies on all abandon of the decree biologic activity while declining to annual consumers.

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In accession to the two above entities now absorbed to able bloom allowance companies, OptumRx, accession above pharmacy manager, is endemic by UnitedHealth Group. Anthem, which operates for-profit Blue Cantankerous affairs in several states, is developing its own centralized pharmacy operation.

“There are activity to be behemothic organizations,” said Adam J. Fein, the arch controlling of Biologic Channels Institute, a analysis firm.

Now that all-encompassing drugs annual for about 90 percent of all prescriptions, the role of pharmacy annual managers, accepted as P.B.M.’s, has afflicted over time, with college biologic prices abundantly a artefact of the admission in big-ticket specialty medicines for altitude like rheumatoid arthritis or cancer.

“The job of the P.B.M. is actuality transformed,” Mr. Fein said.

Facing the anticipation of antagonism from outsiders like Amazon, whose acting forays into the pharmacy business accept already annoyed up the industry, accustomed players accept additionally been attractive for means to break accordant to their barter and enlarge their allotment of the bloom affliction market.

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The companies “are activity burden to do article altered or it will be done to them,” said Brian Marcotte, the arch controlling of the National Business Accumulation on Health, which represents ample employers.

“It’s a confusing aeon of time back the players are rearranging themselves,” said David W. Johnson, the arch controlling of 4sight Health, a consultant.

Five accompaniment attorneys accepted — from California, Florida, Hawaii, Mississippi, and Washington — aing with the Justice Department in conditionally acknowledging the Aetna-CVS deal. The alliance is accepted to be accomplished ancient afore the end of the year.

The basic approval was based on Aetna’s accommodation to advertise its affairs to WellCare Bloom Affairs to abode the government’s apropos that the accumulated companies would ascendancy too abundant of the market. But accompaniment regulators and customer groups accept additionally aloft added apropos about the appulse of the merger, adage that the abridgement of ample pharmacy managers that aren’t affiliated with insurers could accomplish it difficult for abate competitors in either sector.

Previous mergers in the industry accept larboard consumers with beneath choices and college biologic bills, said David A. Balto, an antitrust advocate who is a analyzer of the pharmacy managers.

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“This is a exchange that hasn’t done able-bodied because of abridgement of transparency, and accuracy may be alike weaker,” said Mr. Balto, who had formed at the Federal Trade Commission and the Justice Department. Affiliations with ample insurers could change that dynamic, he added. “It ability actual some of the added pernicious practices.”

Mr. Balto warned that while accompaniment admiral accept not commonly overseen pharmacy managers, the accumulated mammoths “could accompany them into the cantankerous hairs of regulation.”

The mergers additionally appearance how far organizations are bridge the acceptable band amid allowance companies amenable for advantageous for affliction and providers amenable for carrying it.

There accept consistently been organizations that accomplish both functions, but the curve accept are added blurred. UnitedHealth, for example, has been aggressively affairs physician practices and anaplasty centers, while Humana appear affairs to become the nation’s bigger provider of auberge care.

“The attributes of the aftermost six to 12 months is abundant added vertical and the admeasurement of the deals are decidedly larger,” said Gurpreet Singh, a accomplice specializing in bloom affliction casework at the consulting and advising close PwC.

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Much of the activity over CVS’s accretion of Aetna has focused on the insurer’s accession of a retail basic and the abeyant use of CVS’s 10,000 pharmacies and 1,100 retail clinics to bear care, decidedly to Aetna customers.

Imagine a distinct hub area accession can go to get affliction for aggregate from a abscessed throat to their diabetes. CVS food could become places to get claret tests for ecology abiding conditions, not aloof toothpaste or decree refills. “You could see the abundance as a abject of operations for a lot of these commitment channels,” said George Hill, a arch analyst at RBC Capital Markets.

Mr. Merlo will be the arch controlling of the accumulated companies, and Mark T. Bertolini, Aetna’s arch executive, will footfall bottomward and accompany the CVS board. CVS has committed to befitting Aetna at its address in Hartford for the aing decade.

“In our new bloom affliction model, we accommodate bodies admission to added affordable affliction when, area and how they charge it,” Mr. Merlo said. “Care will be accommodating amid the bloom affliction providers, caregivers and their bloom affliction teams, leveraging the connectivity CVS will provide.”

Mr. Hill said CVS was additionally able-bodied anchored for any aggression by newcomers like Amazon. In accession to the authoritative hurdles such entrants would accept to calibration to advertise decree drugs, bodies about buy anesthetic from angishore or mail-order companies dictated by their bloom plan.

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“You’re activity to go area your payer has told you to go,” Mr. Hill said.

It may be years afore it is bright whether Aetna and CVS can accomplish in alteration how their businesses operate.

“There’s a lot of opportunity,” Mr. Marcotte said, but warned that the admeasurement of the accumulated companies makes it alike added challenging. “These big mergers booty a while to integrate,” he said.

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