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The 2025 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers

The 2025 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers
by Adam J. Fein, Ph.D.
(Downloadable 547-page PDF file; Released March 2025)
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The 2025 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers remains the most comprehensive, fact-based tool for understanding the entire U.S. drug pricing, reimbursement, and dispensing system.

It’s your ultimate guide to the complex web of interactions within U.S. prescription drug channels. This unique, encyclopedic resource will benefit pharmaceutical manufacturers, wholesalers, pharmacists, pharmacy owners, hospitals, buyers, benefit managers, managed care executives, policy analysts, investors, consultants—anyone who wants to understand and benefit from this ever-changing industry.

The report was researched and written by Adam J. Fein, Ph.D., one of the world’s leading experts on the industry and author of the influential Drug Channels website. It synthesizes a wealth of statistical data, research studies, financial information, and his unique business consulting experience into a definitive, nonpartisan resource. This new 16th edition integrates information about pharmacy dispensing channels, third-party payers, pharmacy benefit managers (PBMs), patients’ financial contributions, government regulations, and wholesalers.

The 2025 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers retains the overall structure of last year’s edition. However, we have made some significant structural changes to reflect the industry’s evolution. As always, we have updated all market and industry data with the most current information available, including our annual analyses of the market positions of the largest pharmacies, specialty pharmacies, and PBMs. Throughout the report, we have added new industry data, deepened our coverage of many topics, and added more trending information.

The notable new material in this 2025 edition includes the following:

  • Section 4.3. has been new expanded to provide greater coverage of the growing market for patient-paid prescriptions—cash-pay prescriptions and discount cards. A new Section 4.3.3. has been added to this section to provide a more cohesive review of how and why plan sponsors are utilizing these pricing approaches within pharmacy benefits.
  • Section 5.2.3. adds deeper coverage of the smaller PBMs operating in the market. These PBMs distinguishes independent, privately held companies from those partially or fully owned by retail chains and health systems.
  • Section 5.4. has been expanded to provide more complete coverage of the various ways by which plan sponsors compensate PBMs.
  • A new Section 5.2.5. analyzes the private label business of the vertically integrated organizations that also own the largest pharmacy benefit managers.
  • Section 8.4. has been updated and expanded to reflect the emerging importance  of acquisition cost as a basis for pharmacy reimbursement. A new Section 8.4.3. has been added to this section to better explain the implications of acquisition cost reimbursement for pharmacies.
  • Section 11.4. has been reorganized and streamlined to reflect changes in pharmacy direct and indirect remuneration (DIR) fees in Medicare Part D networks.
  • Section 12.3.1. contain a revised analysis of controversies over vertical integration in the drug channel. It also includes a fully updated version of our illustration of these companies.
  • A new Section 12.3.4. reviews how specialty pharmacies are participating in the emerging gene therapy market.
  • We have added significant new material to the sections that discuss the Inflation Reduction Act of 2022. These include an expanded and updated Section 12.4.1., which summarizes the key provisions of the law and current guidance for Medicare Part B and Part D, and Section 12.4.2., which highlights current impacts and future implications of the IRA for the drug channel.
  • Certain material has been shifted from stand-alone sections and integrated into various sections throughout the report. This content includes Amazon’s various roles in the pharmacy industry and discussions of venture-backed pharmacies. Section 1.4.3. now incorporates material on pharmacies’ COVID-19 vaccination activity that had previously been presented in its own section.
  • Where relevant, we have incorporated data and material from the FTC’s two interim reports on the largest three PBMs. Financial exhibits drawn from these reports are included in Section 7.3.1. and Section 12.2.3.
  • There are 268 exhibits in the 2025 edition, compared with 262 in the 2024 edition. Nearly all of the exhibits contain updated data or information that was not presented in previous editions of this report.

Download a free report overview for complete details.

The chart below illustrates the depth and breadth of the 2025 edition. The numbers indicate the report chapter that corresponds to, explains, and analyzes each channel flow.

The chapters are self-contained and do not need to be read in order. We include extensive internal references to help you navigate the entire document and customize it to your specific needs. (These references are clickable hyperlinks in the PDF document.) There are also nearly 1,200 endnotes, most of which have hyperlinks to original source materials.

Please note that purchase of The 2025 Economic Report U.S. Pharmacies and Pharmacy Benefit Managers indicates agreement with the terms and conditions of the End User License Agreement (EULA). License terms, purchaser’s name/email, and a unique transaction ID will be added to the secure PDF file upon checkout. You must purchase a Department/Team or Corporate License if you want to share the report with other people in your company. Upon request, we will refund duplicate purchases of a Corporate License from the same organization.

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LICENSE TERMS

THIS END USER LICENSE AGREEMENT (“Agreement”) governs your use of The 2025 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers (“Report”) provided by HMP Omnimedia, LLC, an HMP Global Company, d/b/a Drug Channels Institute, (“DCI”) under this Agreement made available to, or accessed by, you (“Purchaser”). Purchaser may cite this Report in commercial documents with full and appropriate attribution. Nothing in the license is intended to reduce, limit, or restrict any rights arising from fair use under copyright law or other applicable laws. License terms, purchaser’s name/email, and a unique transaction ID will be added to the secure PDF file upon checkout. We offer three License Options:

  • Single User License: This license allows for use of the Report by one individual person. This person may use the Report on any computer, and may print out the Report, but may not share the Report with any other person or persons. DCI does not permit the purchase of a single user license by individuals working at investment/financial firms, multi-person consulting firms, publicly traded companies, and any organization with more than 10 (ten) employees. Purchasers who violate this limitation are liable for a Department/Team or Corporate License fee.
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The 2025 Economic Report on U.S. Pharmacies and Pharmacy Benefits Managers is protected by copyright law. Unauthorized reproduction or distribution of this report, or any portion of it, may result in severe civil and criminal penalties, and will be prosecuted to the maximum extent of the law. This report may be cited in commercial documents with full and appropriate attribution. Nothing in this license is intended to reduce, limit, or restrict any rights arising from fair use under copyright law or other applicable laws.

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TABLE OF CONTENTS

Introduction and Guide to This Report

PREFACE: INDUSTRY TRENDS AND KEY REPORT THEMES

SECTION I: THE U.S. PHARMACY INDUSTRY

Chapter 1: Industry Overview

  • 1.1. Pharmacy Fundamentals
    • 1.1.1. Defining the Practice of Pharmacy
    • 1.1.2. Pharmacies and the Drug Supply Chain Security Act
  • 1.2. The Products That Pharmacies Dispense
    • 1.2.1. Brand vs. Generic Drugs
    • 1.2.2. Traditional vs. Specialty Drugs
    • 1.2.3. Top Therapy Classes and Average Prescription Costs
  • 1.3. Pharmacy Industry Participants
    • 1.3.1. Pharmacy Dispensing Formats
    • 1.3.2. Differences Among Outpatient Retail Dispensing Formats
    • 1.3.3. Pharmacist Salaries and Employment
  • 1.4. Healthcare and Clinical Services
    • 1.4.1. Retail Healthcare and Provider Services
    • 1.4.2. Medication Therapy Management (MTM), Clinical Services, and Provider Status
    • 1.4.3. Immunization, Vaccination, and COVID-19 Vaccines

Chapter 2: Pharmacy Industry Market Structure

  • 2.1. Industry Trends
    • 2.1.1. Total and 30-Day Equivalent Prescriptions
    • 2.1.2. Prescription Dispensing Revenues
  • 2.2. National Prescription Dispensing Market Share by Company
  • 2.3. Trends by Dispensing Format
    • 2.3.1. Long-Term Trends in Revenues and Prescriptions
    • 2.3.2. Market Changes in 2024
    • 2.3.3. National Retail Chains
    • 2.3.4. Regional Chains and Venture-Backed Pharmacies
    • 2.3.5. Independent Pharmacies
    • 2.3.6. Mail Pharmacies

Chapter 3: Specialty Drugs and Specialty Pharmacies

  • 3.1. Specialty Pharmacies
    • 3.1.1. Defining Specialty Pharmacy
    • 3.1.2. Clinical and Data Services
    • 3.1.3. Accreditation
  • 3.2. Specialty Pharmacy Market Structure
    • 3.2.1. Specialty Pharmacy Industry Market Size
    • 3.2.2. Number of Accredited Specialty Pharmacies
    • 3.2.3. National Market Share for Specialty Dispensing, by Company
    • 3.2.4. Mergers and Acquisitions Among Specialty Pharmacies in 2024
  • 3.3. Trends by Specialty Dispensing Format
    • 3.3.1. Overview of the 2024 Marketplace
    • 3.3.2. Pharmacy Benefit Managers and Health Plans
    • 3.3.3. Independent Specialty Pharmacies
    • 3.3.4. Retail Chains
    • 3.3.5. Hospitals and Health Systems
    • 3.3.6. Physician Practices
    • 3.3.7. Pharmaceutical Wholesalers
  • 3.4. Manufacturer Channel Strategies for Specialty Drugs
    • 3.4.1. Manufacturer-Defined Dispensing Networks and REMS
    • 3.4.2. Compensation for Specialty Pharmacy Clinical and Data Services
    • 3.4.3. Specialty Hub Services and Leading Providers

SECTION II: THIRD-PARTY PAYMENT AND PHARMACY BENEFITS

Chapter 4: Payment and Spending for Prescription Drugs

  • 4.1. U.S. Healthcare Spending
    • 4.1.1. Enrollment in Health Insurance and COVID-19 Impact
    • 4.1.2. Prescription Drugs and U.S. Healthcare Spending
  • 4.2. Payer and Spending Trends
    • 4.2.1. Payment for Outpatient Prescription Drugs
    • 4.2.2. Trends in Drug Spending, by Payer
    • 4.2.3. Trends in Drug Spending: Traditional vs. Specialty
    • 4.2.4. Deconstructing Changes in Cost vs. Utilization
  • 4.3. Patient-Paid Prescriptions
    • 4.3.1. Cash-Pay Prescriptions and Usual & Customary Pricing
    • 4.3.2. Discount Card Programs
    • 4.3.3. Patient-Paid Prescriptions Within Pharmacy Benefits

Chapter 5: Pharmacy Benefit Management

  • 5.1. Overview of Pharmacy Benefit Management
    • 5.1.1. Services for Plan Sponsors
    • 5.1.2. Relationships with Plan Sponsors
    • 5.1.3. Formulary Development and Management
    • 5.1.4. Formulary Exclusions
    • 5.1.5. Utilization Management
  • 5.2. PBM Industry Structure
    • 5.2.1. National Market Share, by PBM
    • 5.2.2. Business Trends for the Largest PBMs
    • 5.2.3. Independent and Health System Owned PBMs
    • 5.2.4. PBM-Affiliated Group Purchasing Organizations
    • 5.2.5. PBM-Affiliated Private Label Products
  • 5.3. Relationships Between PBMs and Pharmacies
    • 5.3.1. Pharmacy Participation in PBM Networks
    • 5.3.2. PBM-Pharmacy Negotiations
    • 5.3.3. Pharmacy Services Administrative Organizations (PSAOs)
  • 5.4. PBM Compensation by Plan Sponsors
    • 5.4.1. Spread Pricing
    • 5.4.2. Pass-Through Pricing

Chapter 6: Consumer Copayments and Coinsurance

  • 6.1. Cost Sharing in Pharmacy Benefit Design
    • 6.1.1. Employer-Sponsored Health Plans
    • 6.1.2. Health Insurance Marketplace Plans
    • 6.1.3. Medicare Part D
    • 6.1.4. Medicaid
  • 6.2. Manufacturer Out-of-Pocket Payment Support and Plan Sponsor Strategies
    • 6.2.1. Copayment Offset Programs and Patient Assistance Programs
    • 6.2.2. Copay Accumulator Adjustment and Copay Maximizers
    • 6.2.3. Alternative Funding Programs
  • 6.3. Out-of-Pocket Expenses
    • 6.3.1. Actual Patient Out-of-Pocket Spending on Prescriptions
    • 6.3.2. Consequences of Pharmacy Benefit Designs

Chapter 7: Narrow Pharmacy Networks

  • 7.1. Overview of Pharmacy Benefit Network Models
    • 7.1.1. Network Options
    • 7.1.2. The Economics of Narrow Pharmacy Networks
    • 7.1.3. Legal and Regulatory Restrictions on Network Design
  • 7.2. Retail Pharmacy Networks
    • 7.2.1. Preferred Retail Networks in Medicare Part D
    • 7.2.2. Narrow Retail Networks in Commercial and Other Plans
    • 7.2.3. Narrow Networks for Maintenance Prescriptions
  • 7.3. Payer-Defined Specialty Dispensing Networks
    • 7.3.1. Commercial Health and Medicare Part D Plans
    • 7.3.2. Specialty Pharmacies’ Role in Buy-and-Bill Channels

SECTION III: DRUG CHANNEL ECONOMICS AND OUTLOOK

Chapter 8: Prescription Reimbursement by Third-Party Payers

  • 8.1. The Basics of Prescription Reimbursement
    • 8.1.1. Estimated Acquisition Cost (EAC)
    • 8.1.2. Dispensing Fees
    • 8.1.3. Service and Data Fees
  • 8.2. Reimbursement for Brand-Name and Specialty Prescriptions
    • 8.2.1. Wholesale Acquisition Cost (WAC) and Average Wholesale Price (AWP) List Prices
    • 8.2.2. AWP Discounts for Pharmacy Reimbursement in 2024
    • 8.2.3. Why Mail Pharmacies Accept Lower Reimbursements
  • 8.3. Reimbursement for Generic Prescriptions
    • 8.3.1. AWP Discounts for Generic Prescriptions in 2024
    • 8.3.2. Maximum Allowable Cost (MAC) Limits and Generic Effective Rates (GER)
    • 8.3.3. Regulations and Laws Regarding MAC Limits
    • 8.3.4. Medicaid and Federal Upper Limits
  • 8.4. Acquisition Cost Reimbursement
    • 8.4.1. Fee-for-Service Medicaid
    • 8.4.2. Commercial Payer and Cash-Pay Pharmacies
    • 8.4.3. Implications of Acquisition Cost Reimbursement for Pharmacies

Chapter 9: Drug Pricing, Rebates, and Payer Costs

  • 9.1. Rebates to Third-Party Payers
    • 9.1.1. How Commercial Payers Access Rebates
    • 9.1.2. Rebates, DIR, and Coverage Gap Discounts in Medicare Part D
    • 9.1.3. The Medicaid Drug Rebate Program
    • 9.1.4. Department of Veterans Affairs
  • 9.2. Gross and Net Drug Pricing
    • 9.2.1. List vs. Net Drug Prices
    • 9.2.2. The Gross-to-Net Bubble in 2024
  • 9.3. Issues with the Rebate System
    • 9.3.1. How Plan Sponsors Use Rebates
    • 9.3.2. Point-of-Sale (POS) Rebates
    • 9.3.2. Controversies Over Rebates and Rebate Reform
  • 9.4. How Prescription Reimbursement, Formulary Rebates, Consumer Copayments, and PBM Expenses Affect Plan Sponsor Costs

Chapter 10: Relationships With Pharmaceutical Wholesalers

  • 10.1. Overview of Wholesale Drug Channels
    • 10.1.1. Industry Participants
    • 10.1.2. Product Distribution
    • 10.1.3. Financial Intermediation
    • 10.1.4. Other Services for Pharmacies, Providers, and Manufacturers
    • 10.1.5. Influence on Pharmacy Reimbursement
  • 10.2. Determinants of Pharmacies’ Acquisition Costs
    • 10.2.1. Wholesaler Pricing of Brand-Name Drugs to Pharmacies
    • 10.2.2. Pharmacy Group Purchasing Organizations
    • 10.2.3. Generic Sourcing Relationships Between Wholesalers and Large Pharmacies

Chapter 11: Pharmacy and Prescription Profitability

  • 11.1. Overall Drugstore Gross Margins
    • 11.1.1. Industry Averages
    • 11.1.2. Chain Drugstores
  • 11.2. Pharmacy Per-Prescription Profits
    • 11.2.1. Sources of Per-Prescription Profits
    • 11.2.2. Average Per-Prescription Profits for Pharmacies
    • 11.2.3. PBM Gross Profits from Network and PBM-Owned Pharmacies
    • 11.2.4. The Impact of Brand-Name Inflation on Prescription Profits
  • 11.3. Lifecycle Profitability for Generic Prescriptions
  • 11.4. Payments from Pharmacies to PBMs
    • 11.4.1. Pharmacy Performance Fees in PBM Networks
    • 11.4.2. Pharmacy DIR Fees in Medicare Part D Networks
  • 11.5. Pharmacy Profits from the 340B Drug Pricing Program
    • 11.5.1. Overview of the 340B Program and Drug Prices
    • 11.5.2. Companies Participating as 340B Contract Pharmacies
    • 11.5.3. Flow of Funds For a 340B Contract Pharmacy Network
    • 11.5.4. Third-Party Administrators of 340B Contract Pharmacy Services
    • 11.5.5. Pharmacy and Covered Entity Profits from 340B Prescriptions

Chapter 12: Outlook and Emerging Trends

  • 12.1. Drug Prices
    • 12.1.1. The Outlook for Brand-Name List Drug Prices and the Gross-To-Net Bubble
    • 12.1.2. The Outlook for Generic Drug Prices
    • 12.1.3. Spending and Payment Projections for Outpatient Prescription Drugs to 2029
  • 12.2. The Outlook for Specialty Drugs
    • 12.2.1. 2024 Update on the Biosimilar Market
    • 12.2.2. Biosimilars Under the Pharmacy Benefit
    • 12.2.3. The Growth and Profitability of Specialty Generic Drugs
    • 12.2.4. The Outlook for Pharmacy Revenues to 2029
  • 12.3. Emerging Trends
    • 12.3.1. Vertical Integration in the Drug Channel: Trends and Controversies
    • 12.3.2. Importation from Canada
    • 12.3.3. State Legislation of the Drug Channel
    • 12.3.4. Specialty Pharmacies’ Role in Gene Therapy Channels
    • 12.3.5. Business and Legislative Trends for 340B Contract Pharmacies
    • 12.3.6. Shakeout and Consolidation in Retail Pharmacy
  • 12.4. The Inflation Reduction Act of 2022
    • 12.4.1. Key Provisions of the IRA for Medicare Parts B and D
    • 12.4.2. Drug Channel Impact and Implications of the IRA

Acronyms and Abbreviations

Endnotes

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LIST OF EXHIBITS

Major Public Companies Operating in U.S. Drug Channels and Primary Roles

The U.S. Pharmacy Distribution and Reimbursement System for Patient-Administered, Outpatient Brand-Name Drugs

Exhibit 1: Timeline of DSCSA Requirements for Pharmacies (Dispensers) and Wholesale Distributors, 2013 to 2026
Exhibit 2: Unbranded and Branded Generics, Share of U.S. Prescriptions, 2003 to 2024
Exhibit 3: State Generic Substitution Policies
Exhibit 4: Dispense As Written (DAW) Product Selection Codes
Exhibit 5: Top Traditional Therapy Categories, Generic Drugs as a Share of Prescriptions and Spending, 2024
Exhibit 6: Specialty Prescriptions, Number and Share of Total, 2020 to 2024
Exhibit 7: Factors Determining the Classification of a Specialty Drug, By PBM, 2024
Exhibit 8: Formulary Agreement on Specialty Drug Classification, by PBM, 2023
Exhibit 9: Top Therapy Categories, Share of Non-Discounted Purchases and Average Brand-Name and Generic Prescription Costs, 2024
Exhibit 10: Average Annual Number of Prescriptions per Pharmacy, by Retail Dispensing Format, 2024
Exhibit 11: Average Annual Prescription Revenue per Pharmacy Outlet, by Retail Dispensing Format, 2024
Exhibit 12: Top Four Reasons for Pharmacy Selection, by Dispensing Format
Exhibit 13: Average Number of Retail Pharmacies per County, by Dispensing Format and Degree of Urbanization, 2020
Exhibit 14: Pharmacist Work Activities, by Practice Setting, 2022
Exhibit 15: Customer Satisfaction with Pharmacies, by Dispensing Format and Company, 2024
Exhibit 16: Customer Satisfaction with Pharmacies, By Dispensing Format, 2022 vs. 2024
Exhibit 17: Pharmacist Employment and Salary, by Practice Setting, 2023
Exhibit 18: Share of Pharmacist Employment, by Industry, 2013 to 2033
Exhibit 19: Pharmacists and Healthcare Workers, Change in Annual Average Salary, by Employer, 2014 to 2023
Exhibit 20: Coverage for Retail Clinics by Employer-Sponsored Plans, 2010 to 2023
Exhibit 21: Consumer Views on Products and Services Associated with Retail Stores or Pharmacies, 2024
Exhibit 22: Providers of Medication Therapy Management Services, Medicare Part D
Exhibit 23: Completion Rate of Medication Therapy Management Services, Medicare Part D, by Plan Type, 2020 to 2024
Exhibit 24: Current Procedural Terminology (CPT) Codes Used by Pharmacists
Exhibit 25: Consumers’ Level of Trust in Pharmacists to Perform Various Healthcare Services
Exhibit 26: CPESN Networks and Pharmacies, 2018 to 2024
Exhibit 27: Adult Influenza Vaccines Administered, Pharmacies vs. Physician Offices, 2019–20 to 2024-25 Seasons
Exhibit 28: Total U.S. Pharmacy Industry Prescription Revenues, Prescriptions, and Locations, by Dispensing Format, 2024
Exhibit 29: Prescriptions, Annual Total and Growth, 2020 to 2024
Exhibit 30: 30-Day Equivalent Prescriptions, Annual Total and Growth, 2020 to 2024
Exhibit 31: 90-Day Prescriptions as a Percentage of Total Prescriptions, by Dispensing Format, 2017 to 2024
Exhibit 32: Pharmacy Industry Prescription Dispensing Revenues, Annual Total and Growth, 2020 to 2024
Exhibit 33: Prescription Dispensing Revenues from GLP-1 Products, By Dispensing Format, 2020 to 2024
Exhibit 34: Largest 15 U.S. Pharmacies, by Total Prescription Revenues, 2024
Exhibit 35: Total Change in 30-Day Equivalent Prescriptions Dispensed and Prescription Revenues, by Pharmacy Type, 2014 vs. 2024
Exhibit 36: 30-Day Equivalent Prescriptions Dispensed per Location, by Dispensing Format, 2010 to 2024
Exhibit 37: Number of 30-Day Equivalent Prescriptions, by Dispensing Format, 2023 vs. 2024
Exhibit 38: Prescription Dispensing Revenues, by Dispensing Format, 2023 vs. 2024
Exhibit 39: Year-over-Year Change in Same-Store Prescription Count, by Chain, 2020 to 2024
Exhibit 40: Largest Regional Chain Drugstores, by Total Prescription Revenues, 2024
Exhibit 41: Number of Independent Pharmacies, 2001 to 2024
Exhibit 42: Wholesaler-Owned Pharmacy Franchise and Marketing Groups, 2024
Exhibit 43: U.S. Pharmacy Franchise Locations, by Company, 2015 to 2024
Exhibit 44: Customer Satisfaction with Mail Pharmacies, by Company, 2024
Exhibit 45: Share of Mail Pharmacy Dispensing Revenues, by Company, 2024
Exhibit 46: Importance of Specialty Pharmacy Services to Patients
Exhibit 47: Specialty Prescription Dispensing Revenues, Annual Total and Growth, 2020 to 2024
Exhibit 48: Specialty Prescription Dispensing Revenues as a Percentage of Total, 2013 to 2024
Exhibit 49: Specialty Drugs as a Percentage of Payers’ Pharmacy Benefit Spending, by PBM, 2021 vs. 2023
Exhibit 50: Number of Locations with Specialty Pharmacy Accreditation, by Organization, 2015 to 2024
Exhibit 51: Locations with URAC Specialty Pharmacy Accreditation, 2008 to 2024
Exhibit 52: Prescription Revenues and Market Share from Specialty Pharmaceuticals, by Company, 2024
Exhibit 53: Merger and Acquisition Transactions, Specialty Pharmacy and Related Services, 2014 to 2024
Exhibit 54: Pharmacy Locations with Specialty Pharmacy Accreditation, by Corporate Ownership, 2024
Exhibit 55: Hospitals and Health System Pharmacy Locations With Specialty Pharmacy Accreditation, 2017 to 2024
Exhibit 56: Specialty Drug Prescription Revenues, by Dispensing Format, 2024
Exhibit 57: Retail Companies with Specialty Pharmacy Businesses, 2024
Exhibit 58: Hospital and Clinic Share of Oral Oncology Market, 2017 to 2024
Exhibit 59: Hospitals’ Perceived Barriers to Accessing Specialty Pharmacy Networks, 2020 vs. 2022
Exhibit 60: Initial and Final Prescription Claim Status for Brand-Name Oral Oncology Therapies, by Site of Dispensing, 2023
Exhibit 61: Physician Employment, by Practice Ownership, 2012 vs. 2022
Exhibit 62: Share of Oncologists in Practices with Medically Integrated Dispensing, by Practice Setting, 2010 to 2024
Exhibit 63: Specialty Pharmacy Network Size, by Number of Pharmacies, 2025
Exhibit 64: Specialty Pharmacy Networks, Participation Rate by Company, 2025
Exhibit 65: Participation in Exclusive Specialty Pharmacy Networks, by Company, 2025
Exhibit 66: Frequency of Manufacturer Contracting for Specialty Pharmacy Services, by Type of Service
Exhibit 67: Example of Specialty Hub Workflow
Exhibit 68: Leading Specialty Hub Services Providers and Ownership, 2024
Exhibit 69: Chapter Coverage of Flows in the U.S. Distribution and Reimbursement System
Exhibit 70: Comprehensive Health Insurance Enrollment, by Payer, 2021 to 2023
Exhibit 71: Medicaid Enrollment, 2005 to 2024E
Exhibit 72: Number of Covered Lives, By Insurer and Payer, 2024
Exhibit 73: Share of U.S. National Health Expenditures, by Category, 2023
Exhibit 74: Share of U.S. National Health Expenditures, by Major Spending Category, 1983 to 2023
Exhibit 75: Growth Rate in U.S. National Health Expenditures, by Major Spending Category, 2010 to 2023
Exhibit 76: Outpatient Prescription Drug Expenditures, by Source of Payment, 2023
Exhibit 77: Outpatient Prescription Drugs as a Share of Payer’s Total Health Expenditures, by Payer, 2005 to 2023
Exhibit 78: Share of Outpatient Prescription Drug Dispensing, by Source of Payment, 2023
Exhibit 79: Prescription Expenses per Person, by Age, 2022
Exhibit 80: Prescription Drug Utilization Among Seniors, 1988 to 2020
Exhibit 81: Change in Net Spending for Outpatient Prescription Drugs, by Payer, 2022 vs. 2023
Exhibit 82: Total Expenditures and Consumer Out-of-Pocket Spending for Hospital Care vs. Prescription Drugs, 2023
Exhibit 83: Change in Commercial Payer Net Drug Spending, Traditional vs. Specialty Drugs, 2014 to 2023
Exhibit 84: Change in Commercial Payer Net Drug Spending, Traditional vs. Specialty Drugs, by PBM, 2023
Exhibit 85: Components of Change in Outpatient Prescription Drug Spending, 2018 to 2023
Exhibit 86: Components of Change in Commercial Payer Net Specialty Drug Spending, by PBM, 2023
Exhibit 87: Cash-Pay Prescriptions as a Share of Total Prescriptions, 2017 to 2024
Exhibit 88: Usual & Customary Cash Prescription Prices vs. Pharmacy Acquisition Costs, Generic and Brand-Name Drugs, 2014 vs. 2019
Exhibit 89: Venture Capital-Backed Cash-Pay Pharmacies and Total Funding, 2025
Exhibit 90: Cash-Pay Pharmacies, Estimates of Total Prescription Savings vs. Medicare Part D, 2020 to 2023
Exhibit 91: Discount Card Claims as Share of Total Equivalent Prescriptions, by Vendor, 2019 to 2024
Exhibit 92: Share of Discount Card Claims vs. Overall Prescription Share, by Dispensing Format, 2024
Exhibit 93: Pharmacy Distribution and Reimbursement System for Outpatient Generic Drugs with a Discount Card
Exhibit 94: Prescription Economics with a Discount Card—Traditional Generic Drug Example
Exhibit 95: GoodRx, Prescription Revenues and Consumer Out-of-Pocket Cost, 2016 to 2024
Exhibit 96: Employers Adoption of Patient-Paid Prescriptions with Benefit Design, By Employer Size, 2024
Exhibit 97: Pharmacy Benefit Management Contracting Approach, by Company Size, 2019 vs. 2024
Exhibit 98: PBM Selection Factors, by Type of Plan Sponsor, 2024
Exhibit 99: Adoption of PBM National Formulary, by Type of Plan Sponsor, 2024
Exhibit 100: Number of Products on PBM Formulary Exclusion Lists, by PBM, 2012 to 2025
Exhibit 101: Number of Formulary Exclusions for Oncology Products, 2017 to 2024
Exhibit 102: Formulary Coverage for Humira and Its Biosimilars, by PBM, 2025
Exhibit 103: Prevalence of Utilization Management Tools, Commercial Plan Sponsors, 2014 vs. 2024
Exhibit 104: Use of Prior Authorization and Step Therapy for Single-Source Brand-Name Drugs, by Therapeutic Class, 2020
Exhibit 105: Prevalence of Utilization Management Tools, Medicare Part D Plans, 2024
Exhibit 106: Prevalence of Utilization Management Tools to Manage Oncology Drug Costs, By Type of Drug, Medicare Part D Plans, 2020
Exhibit 107: PBM Market Share, by Total Equivalent Prescription Claims, 2023 vs. 2024
Exhibit 108: Express Scripts, Annual Prescription Claims, by Channel, 2019 to 2024
Exhibit 109: Plan Sponsors’ Satisfaction with PBM Transparency, by PBM Size, 2024
Exhibit 110: PBM-Owned Purchasing Groups and Participation, 2025
Exhibit 111: Largest Pharmacy Services Administrative Organizations, by Membership and Ownership, 2024
Exhibit 112: Key Components of PBM Compensation
Exhibit 113: Administrative Fees as a Percentage of WAC, by PBM, 2019
Exhibit 114: Share of Plans Using Various Compensation Elements in PBM Contracts, By Type of Plan Sponsor, 2023
Exhibit 115: Average PBM Network Spread in Medicaid Managed Care, by State, 2018 to 2019
Exhibit 116: Imatinib Mesylate, Fee-for-Service and Managed Medicaid Spreads, 2017 to 2024
Exhibit 117: Common Pharmacy Benefit Plan Designs
Exhibit 118: Share of Employees Covered by a High-Deductible Health Plan, 2006 to 2024
Exhibit 119: Distribution of Cost Sharing Formulas for Prescription Drug Benefits in Employer-Sponsored Plans, by Plan Type, 2024
Exhibit 120: Type of Cost Sharing for Prescription Drug Benefits, Employer-Sponsored Plans Without High Deductibles, by Benefit Tier, 2024
Exhibit 121: Type of Cost Sharing for Prescription Drug Benefits, Employer-Sponsored Plans with High Deductibles, by Benefit Tier, 2024
Exhibit 122: Average Cost Sharing by Prescription Drug Tier, Employer-Sponsored Plans, 2024
Exhibit 123: Number of Specialty Drug Cost-Sharing Tiers, by Type of Plan Sponsor, 2023
Exhibit 124: Distribution of Coinsurance Structures for Prescription Drug Benefits, Employer-Sponsored Plans, Fourth and Specialty Tiers, 2024
Exhibit 125: Percentage of Covered Workers with No Prescription Drug Coverage Before Annual Deductible, by Plan Type, 2019 vs. 2024
Exhibit 126: Percentage of Covered Workers with Pharmacy Benefit Deductibles, Employer-Sponsored Plans, 2005 to 2024
Exhibit 127: Enrollment in Individual Insurance Market, by Source of Plan, 2015 to 2024
Exhibit 128: Type of Cost Sharing for Prescription Drug Benefits, Silver Health Insurance Marketplace Plans, 2024
Exhibit 129: Average Cost Sharing by Prescription Drug Tier, Silver Health Insurance Marketplace Plans, 2024
Exhibit 130: Presence of Separate Prescription Drug Deductibles in Silver Plans on Health Insurance Marketplaces, 2014 to 2024
Exhibit 131: Medicare Part D Enrollment, by Type of Plan, 2010 to 2024
Exhibit 132: Standard Medicare Prescription Drug Benefit, 2024
Exhibit 133: Monthly Rebate per Medicare Advantage Beneficiary, by Extra Benefit Type, 2020 to 2025
Exhibit 134: Type of Cost Sharing for Prescription Drug Benefits, Medicare Part D Plans, 2024
Exhibit 135: Median Cost Sharing by Prescription Drug Tier, Medicare Part D PDPs, 2024
Exhibit 136: Median Cost Sharing by Prescription Drug Tier, Medicare Advantage Plans, 2024
Exhibit 137: Distribution of Coinsurance Rates for Specialty Drugs, Medicare Part D Plans, 2023
Exhibit 138: Median Cost Sharing Amounts for 14 Largest Medicare Part D Plans, 2024
Exhibit 139: Summary of Plan Sponsors’ Tools for Accessing Manufacturer Patient Support Funds to Offset Drug Spending
Exhibit 140: Prevalence of Copayment Offset Programs for Specialty Drugs, 2020 vs. 2024
Exhibit 141: Value of Manufacturer Copayment Offset Programs, 2019 to 2024
Exhibit 142: Share of Prescriptions Using Manufacturer Cost Sharing Assistance for Brand-Name Drugs, by Therapeutic Class, 2023
Exhibit 143: Distribution of Annual Value of Manufacturer Copay Offset Programs, 2024
Exhibit 144: Commercial Plan Sponsor Views on Specialty Copayment Assistance Programs, 2018 vs. 2024
Exhibit 145: Pharmacist Views on Copayment Assistance Programs, 2020
Exhibit 146: Pharmaceutical Manufacturer Charitable Foundations, by Total Giving, 2021 to 2023
Exhibit 147: Prescription Economics for Copay Accumulators, Maximizers, and Alternative Funding Programs—Specialty Brand-Name Drug Example
Exhibit 148: Copay Accumulator Adjustment and Copay Maximizers, Implementation in Commercial Insurance, 2018 to 2024
Exhibit 149: Share of Patients with Copay Accumulator Adjustment and Copay Maximizers Applied to Benefit, by Therapeutic Class, 2019 vs. 2023
Exhibit 150: Use of Alternative Funding Programs (AFPs) in Commercial Insurance, 2021 to 2023
Exhibit 151: Consumers’ Out-of-Pocket Spending Share of Outpatient Prescription Drug Expenditures, 1963 to 2023
Exhibit 152: Per Capita Out-of-Pocket Spending on Outpatient Prescription Drugs, Nominal vs. Inflation-Adjusted, 2010 to 2023
Exhibit 153: Average Per-Prescription Patient Out-of-Pocket Costs, by Type of Prescription, 2015 vs. 2023
Exhibit 154: Distribution of Annual Patient Out-of-Pocket Spending, by Type of Health Plan, 2023
Exhibit 155: Share of Employees with Cost Sharing Reduced or Waived for Medications to Treat Chronic Conditions, by Company Size, 2024
Exhibit 156: Products with Cost Sharing Waived in High-Deductible Employer-Sponsored Health Plans, by Medication Class, 2021
Exhibit 157: Type of Cost Sharing for Out-of-Pocket Spending on Brand-Name Prescriptions, 2015 vs. 2024
Exhibit 158: Share of Prescriptions vs. Final Out-of-Pocket Spending, by Type of Cost Sharing and Therapy, 2021
Exhibit 159: Average Out-of-Pocket Spending on Prescription Drugs for Medicare Part D Beneficiaries, by LIS Status, 2007 to 2022
Exhibit 160: Number of Medicare Part D Beneficiaries with Out-of-Pocket Obligations Above the Catastrophic Threshold, 2007 to 2022
Exhibit 161: Impact of IRA on Average Annual Out-of-Pocket Part D Spending, by Medical Condition, 2025
Exhibit 162: New-to-Product Prescription Abandonment, by Patient Out-of-Pocket Cost, 2023
Exhibit 163: Consumer Understanding of Health Insurance Terms, by Racial/Ethnic Group
Exhibit 164: CVS Health, Quarterly Retail/LTC Prescription Revenues, 2019 to 2024
Exhibit 165: Summary of Pharmacy Benefit Network Design Options
Exhibit 166: Driving Distance to Nearest Retail Pharmacy, by Degree of Urbanization, 2020
Exhibit 167: Medicare Part D PDPs with Preferred Pharmacy Networks, 2011 to 2025
Exhibit 168: Medicare Advantage Prescription Drug (MA-PD) Plans with Preferred Pharmacy Networks, by Plan Type, 2025
Exhibit 169: Participation as a Preferred Cost Sharing Pharmacy in Selected Medicare Part D PDPs, by Retail Chain, 2025
Exhibit 170: Enrollment in Medicare Part D PDPs with Preferred Cost Sharing Networks, by Pharmacy Chain, 2024 vs. 2025
Exhibit 171: Participation as a Preferred Cost Sharing Pharmacy in Selected Medicare Part D PDPs, by PSAO, 2025
Exhibit 172: Share of Employer-Sponsored Plans with a Preferred Retail Pharmacy Network, 2012 to 2024
Exhibit 173: Number of Locations in the TRICARE Retail Pharmacy Network, By Dispensing Format, 2021 to 2024
Exhibit 174: Health Systems’ Requirements for Employee Use of an In-House Pharmacy, 2024
Exhibit 175: Mandatory Mail Pharmacy Utilization for Maintenance Medications, Employer-Sponsored Plans, 2013 to 2024
Exhibit 176: TRICARE, Share of Net Spending on Outpatient Prescriptions, by Dispensing Outlet, 2013 to 2023
Exhibit 177: Rebate Guarantees Affected by Not Using PBM-Affiliated Specialty Pharmacy, Employer-Sponsored Plans, 2018 to 2023
Exhibit 178: Share of Large Employers with Restricted Specialty Pharmacy Network, by Network Size, 2011 to 2024
Exhibit 179: Share of Prescriptions and Dispensing Revenues from Specialty Drugs, PBM-Affiliate Pharmacies, 2017 to 2022
Exhibit 180: Health Systems’ Requirements for Employee Use of Internal Specialty Pharmacies, 2022
Exhibit 181: Reimbursement for Provider-Administered Specialty Drugs vs. Specialty Pharmacies, by Site of Care and Therapeutic Class, 2021
Exhibit 182: White Bagging Approach for Distribution and Reimbursement of Provider-Administered Outpatient Drugs
Exhibit 183: UnitedHealthcare, White Bagging Requirements for Hospital Outpatient Providers, by Specialty Pharmacy, 2025
Exhibit 184: Drug Sourcing for Infused Oncology Therapies, by Practice Type and Source, 2019 vs. 2024
Exhibit 185: Payer Reimbursement and Patient Out-of-Pocket Obligation for Oncology Drugs, White Bagging vs. Buy-and-Bill, 2020
Exhibit 186: Share of Hospitals Permitting Pharmacy Sourcing of Infused Drugs, by Source, 2020 vs. 2022
Exhibit 187: Payer Methodologies for Computing a Pharmacy’s Estimated Acquisition Cost
Exhibit 188: Distribution of Retail Pharmacy Dispensing Fees, 2020
Exhibit 189: Pharmacy AWP Reimbursement and Copayments for Brand-Name Prescriptions, by Dispensing Format, 2024
Exhibit 190: Plan Sponsor Tactics to Increase Use of 90-day Prescriptions, by Dispensing Channel, 2023
Exhibit 191: Imatinib Mesylate, AWP and WAC Prices, By Manufacturer, 2024
Exhibit 192: AWP Reimbursement and Copayments for Generic Prescriptions, by Dispensing Format, 2024
Exhibit 193: Basis of Retail Pharmacy Reimbursement for Generic Drug Prescriptions, by Method, 2020
Exhibit 194: Pharmacy Reimbursement in Medicaid, Fee-for-Service vs. Managed Medicaid
Exhibit 195: Pharmacy Reimbursement Methodology and Dispensing Fee, Largest Fee-for-Service State Medicaid Programs, 2024
Exhibit 196: Share of Employers Receiving Rebates for Traditional and Specialty Drugs, 2014 vs. 2024
Exhibit 197: PBM Rebate Arrangements for Traditional and Specialty Medications in Employer-Sponsored Plans, 2014 vs. 2024
Exhibit 198: Use of Manufacturers’ Rebate and Other Payments to PBMs, Texas, 2016 to 2023
Exhibit 199: Value of Direct and Indirect Remuneration (DIR) in Medicare Part D, 2012 to 2024
Exhibit 200: Medicare Part D, Value of Direct and Indirect Remuneration (DIR), by Source and Type of Drug, 2022
Exhibit 201: Value of Manufacturers’ Coverage Gap Discounts in Medicare Part D, 2014 to 2024
Exhibit 202: Medicaid Program, Gross Prescription Spending and Prescriptions, Fee-for-Service vs. Managed Care, 2023
Exhibit 203: Medicaid, Gross vs. Net Spending on Outpatient Drugs, 2015 to 2023
Exhibit 204: Brand-Name Drugs, Change in Average List and Net Prices, 2014 to 2024
Exhibit 205: Change in List vs. Net Price, by Manufacturer, 2023
Exhibit 206: Average Difference Between List and Net Prices, by Therapeutic Area, 2012 to 2024
Exhibit 207: Total Value of Pharmaceutical Manufacturers’ Gross-to-Net Reductions for All Brand-Name Drugs, 2020 to 2024
Exhibit 208: Components of Pharmaceutical Manufacturers’ Gross-to-Net Gap for All Brand-Name Drugs, by Source, 2024
Exhibit 209: Components of Gross-to-Net Bubble, Brand-Name Insulin Products, 2012 vs. 2022
Exhibit 210: Components of Gross-to-Net Bubble, Johnson & Johnson Innovative Medicines, 2023
Exhibit 211: Application of Pharmacy Benefit Rebates in Employer-Sponsored Healthcare Plans, 2024
Exhibit 212: Larger Employers’ Challenges Switching from Pharmacy Benefit Rebates, 2024
Exhibit 213: Prescription Economics for a Third-Party Payer—Traditional Brand-Name Drug Example
Exhibit 214: Prescription Economics for a Third-Party Payer—Traditional Brand-Name Drug Example in a High-Deductible Health Plan
Exhibit 215: Prescription Economics for a Third-Party Payer—Traditional Brand-Name Drug Example in High-Deductible Health Plan with Point-of-Sale Rebates
Exhibit 216: Prescription Economics for a Third-Party Payer—Specialty Brand-Name Drug Example
Exhibit 217: U.S. Drug Distribution and Related Revenues at Big Three Wholesalers, 2024
Exhibit 218: Determination of a Pharmacy’s Brand-Name Drug Acquisition Cost from a Wholesaler
Exhibit 219: Pharmacy Buying Groups and Primary/Preferred Wholesaler Relationships, by Number of Pharmacies, 2024
Exhibit 220: Share of U.S. Generic Purchasing Volume, by Organization, 2024
Exhibit 221: Overall Gross Margins for Chain and Independent Drugstores, 2006 to 2024
Exhibit 222: Total Gross Profits for Chain and Independent Drugstores, 2020 to 2024
Exhibit 223: Overall Gross Margins for Chain and Independent Drugstores, by Company, 2024
Exhibit 224: Prescriptions as a Percentage of Revenues, by Company, 2013 to 2024
Exhibit 225: Components of a Pharmacy’s Cost of Nonspecialty Dispensing, by State
Exhibit 226: Average Cost of Dispensing in Retail Pharmacies, by Dispensing Format and State
Exhibit 227: Example of Brand-Name Prescription Economics for a Retail Pharmacy
Exhibit 228: Independent Pharmacies, Average Per-Prescription Gross Profits and Margins, 2019 to 2023
Exhibit 229: BrightSpring Health Services, Average Per-Prescription Gross Profits and Margins, 2020 to 2024
Exhibit 230: Top Three PBMs, Sources of Gross Profit, 2024
Exhibit 231: Effect of Brand-Name List Price Increases on a Prescription’s Gross Profit
Exhibit 232: Median AWP Discount for Generic Drugs Sold to Retail Pharmacies, by Number of Manufacturers, 2024
Exhibit 233: Life Cycle of Per-Prescription Gross Profits, Brand vs. Multisource Generic
Exhibit 234: Types of Pharmacy Performance Metrics Used by Payers, by Plan Type
Exhibit 235: Net Value of Pharmacy DIR Fees in Medicare Part D, 2012 to 2024
Exhibit 236: 340B Drug Pricing Program, Purchases by Covered Entities, 2010 to 2024
Exhibit 237: Estimated 340B Discounts on Brand-Name Drugs, by Therapeutic Class, 2018
Exhibit 238: 340B Contract Pharmacy Locations, 2010 to 2024
Exhibit 239: 340B Contract Pharmacy Relationships, by Entity Type and Company, 2024
Exhibit 240: Growth in Value of Non-340B vs. 340B Purchases at List Prices, by Channel, 2019 to 2023
Exhibit 241: 340B Covered Entities, by Number of Contract Pharmacies, 2024
Exhibit 242: Flow of Funds and Product for a 340B Contract Pharmacy Network
Exhibit 243: 340B Software Vendors with Drug Channel Ownership, 2024
Exhibit 244: How a 340B Covered Entity Generates Funds from the 340B Program
Exhibit 245: 340B Prescription Economics for a Covered Entity, a Contract Pharmacy, and a Patient—Specialty Brand-Name Drug Example
Exhibit 246: Total Gross Profits from 340B Contract Pharmacy, by Company, 2019 to 2023
Exhibit 247: Summary of List Price Reductions for Selected Brand-Name Drugs, 2024/2025
Exhibit 248: Average Year-over-Year Change in Pricing of Mature Generic Drugs, Oral vs. Injectable, 2015 to 2024
Exhibit 249: Generic Drug Approvals, FDA, 2014 to 2024
Exhibit 250: Actual and Projected Growth Rates in National Health and Outpatient Prescription Drug Expenditures, 2019 to 2029
Exhibit 251: Source of Payment for Outpatient Prescription Drug Expenditures, 2029
Exhibit 252: Number of U.S. Biosimilar Approvals, by Product Type, 2015 to 2025
Exhibit 253: Insulin Glargine, Share of New-to-Brand Prescriptions Written vs. Dispensed, 2023
Exhibit 254: Physician Perceptions of Biosimilars, by Specialty, 2023
Exhibit 255: Top Specialty Therapy Categories, Generic Drugs as a Share of Prescriptions and Net Spending, 2024
Exhibit 256: Nonbiological Specialty Drugs, Pharmacy Acquisition Cost per Unit for Brand-Name vs. Generic Version, 2024
Exhibit 257: Imatinib Mesylate, Medicare Part D Prescription Reimbursement vs. Pharmacy Acquisition Cost, 2017 to 2023
Exhibit 258: Dispensing Spreads for Specialty Generic Drugs at PBM-Affiliated Pharmacies, 2017 to 2021
Exhibit 259: Total Brand Revenues Lost to Generic and Biosimilar Launches, by Product Type, 2019 to 2028
Exhibit 260: Pharmacy Industry Prescription Revenues, Traditional vs. Specialty Drugs, 2019 to 2029
Exhibit 261: Vertical Business Relationships Within the U.S. Drug Channel, 2025
Exhibit 262: Annual Change in Value of 340B Purchases, by Channel, 2019 to 2023
Exhibit 263: Share of 340B Purchases, by Channel, 2018 to 2023
Exhibit 264: Pharmacy Locations Acquired, by Company, 2010 to 2024
Exhibit 265: U.S. Retail Pharmacy Store Count, CVS vs. Walgreens, 2014 to 2024
Exhibit 266: Standard Medicare Prescription Drug Benefit, 2024 vs. 2025
Exhibit 267: Prices for Products Selected for 2026 Medicare Drug Price Negotiation Program, by Total and Out-of-Pocket Spending
Exhibit 268: Number of Stand-Alone Medicare Part D Prescription Drug Plans, 2007 to 2025

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