Bill Roth, IntegriChain

This column marks the first of a six-part series on “Popping the Gross-to-Net (GTN) Bubble" in the pharmaceutical industry. The “bubble” refers to the widening gap between the gross revenue (the total sales at list price) and the net revenue (the amount received by the manufacturer after discounts, rebates, fees, and other adjustments). This gap has been expanding significantly in recent years due to changes in regulations surrounding pricing in the industry; expansion of government programs; expansion of the use of programs such as 340B; and increased demands for rebates from pharmacy benefit managers (PBMs) and insurers. It is set to continue to widen further with programs that are still to launch, such as the maximum fair price as part of the Inflation Reduction Act.

My intention of this series isn’t just to point to the bubble, which most pundits see currently as roughly $335 billion to $350 billion and growing. Ultimately, I intend to discuss the future of pharmaceutical pricing and the bubble, innovative ideas to address the bubble, how some therapeutic areas and certain product archetypes and classes are more or less sensitive to the bubble, who wins and loses if the bubble grows or pops/deflates, and mechanically, how rebates and discounts fuel the bubble. For this first column, we should simply begin by understanding the bubble itself.

When someone in our industry refers to the gross sales, this refers to the wholesale acquisition cost (WAC) or list price of a product times the units sold in a given period of time. As the vast majority of rebates, discounts, fees, or other price concessions begin with the WAC, this is our starting point of the calculation.

From there, we start to see rebates, discounts, and other price concessions offered. I always like looking at the price concessions by payer type and by physical channel. It gives a weighted view to the flow of the dollar. This view also allows baseline visibility to where there can be duplicate discounts and other areas of potential overpayments. The trick to understanding the baseline numbers are to tease apart which are statutory and required, which are negotiable, and which ones are truly discretionary. The default view by many in the industry is that these rebates and discounts are intended to secure a more favorable position on insurance formularies, making the drug more accessible to patients but reducing the actual revenue manufacturers receive. The reality can be somewhat different.

This is the amount that pharmaceutical manufacturers actually retain after these rebates, discounts, and other adjustments. When publicly traded manufacturers disclose their revenues, they always speak in terms of net revenues, but rarely do they disclose the full walk-down of all the price concessions that lead to the net revenue number.

The expanding gross-to-net bubble has significant implications for the industry. While it sounds like a good idea to “pop” the bubble, most payers, providers, pharmacies, group purchasing organizations, and distributors and their business models depend on the high WAC and the low cost. So, knowing the impacts of the deployment of any strategy are key to any successful initiative around a gross-to-net improvement. What’s maddening at the moment is the fact that more drugs that are coming to market begin with a significant reduction from GTN and attempt to make improvements over time. The challenge is that many of the pricing and price change options have been recently constrained. Long-range financial planning is now crucial to the success of managing this.

The term bubble implies that the situation is unsustainable and may eventually burst due to rising public and regulatory scrutiny. Policymakers are increasingly concerned that the system is inefficient and opaque, leading to discussions around price reforms and more transparent pricing models.

Neck-in-neck with the challenges of gaining product approval, the gross-to-net bubble is the key financial hurdle and hardship facing the pharma industry. Products and life sciences organizations that cannot adequately contend
with this issue face product or even company discontinuation.

Certain types of pharmaceuticals are indeed more impacted by the gross-to-net bubble than others. Generally, high-cost brand-name drugs, especially those in competitive therapeutic areas, face the largest GTN disparities. Here’s a breakdown of the categories most affected.

Drugs for chronic conditions such as diabetes (e.g., insulin), cardiovascular diseases, and asthma are particularly affected because they are commonly prescribed and often require ongoing, long-term use. Manufacturers of these drugs offer significant rebates to ensure their products are included on formularies, as payers seek to manage the high costs associated with chronic care.

 These high-cost medications for complex conditions—such as rheumatoid arthritis, oncology, and multiple sclerosis—tend to see large GTN gaps. Due to intense competition and high list prices, these drugs typically have substantial rebates, discounts, and other concessions, especially given that many are administered under healthcare professional oversight and subject to payer negotiations.

 For drugs in areas with multiple treatment options—such as rheumatoid arthritis or cholesterol management—manufacturers often offer large rebates to secure preferred positions on PBM and insurer formularies. The competition drives aggressive discounting, leading to significant erosion between gross and net revenue.

 Drugs heavily impacted by the Medicaid rebate program or the 340B Drug Pricing Program experience large reductions in net revenue. Under Medicaid, mandatory rebates often exceed 23% of the drug's average manufacturer price, with additional discounts if the drug’s price rises faster than inflation. The 340B Drug Pricing Program also mandates that certain healthcare providers receive discounted drug prices, significantly reducing revenue for manufacturers in these channels.

 Although not traditionally considered under the GTN bubble, biosimilars are increasingly influenced by these pressures. To compete with originator biologics, biosimilar manufacturers offer significant discounts, which further compounds the bubble effect in the biologic space.

After spending more than 30 years in the industry and working with a few hundred manufacturers across the majority of therapeutic areas and drug classes, I see a few main reasons why the pharmaceuticals manufacturer struggle with the concept and, consequently, the strategies deployed. The first issue is the siloes in the commercialization group. There are five main commercial functions and two financial functions that commonly don’t align well. If the marketing, field sales, payer sales, channel sales, patient access and affordability, finance, and government pricing teams are part of a company with more than just a few products, the chances of either these seven teams understanding one another or reporting into a combined function with full P&L responsibility are all very low.

Stay tuned in future issues for the next column in this series where I’ll explore the types of rebates and discounts, and how these fuel the bubble. This will also lay the foundation for where the bubble can be mitigated and how to improve net revenues. 

Bill Roth is General Manager and Managing Partner of IntegriChain’s consulting business, which includes Blue Fin Group, a strategy consulting company he started in 2001, and the IntegriChain advisory services business.

Articles

A crash course on the bubble itself, including therapeutic areas most affected.

Going Inside the Gross-to-Net Bubble and Its Nuances

, there was one main concern on our minds: how to launch a general medicine brand into a progressively changing and fragmenting retail and ecommerce landscape. The historical model of “stick it in wholesale and pull through retail” clearly no longer worked. Almost all the brands launched into this model failed to meet their forecasts. At Blue Fin Group, we received call after call from our manufacturer clients complaining that branded prescriptions were increasingly being turned away by retail pharmacies of all kinds, with estimated abandonment rates reaching 50% to 60%. These were products with strong formulary coverage and reasonable affordability profiles for all forms of payer sponsored lives.

We believed the first signs of this issue became evident with the struggles faced by medications in the specialty lite category: product priced above $650 or below $2,000 a month. A solid example was the original pricing of PCSK9 inhibitors launched in 2015. Our attention at the time was solidly on this specialty lite area, but that product archetype simply proved to be the canary in the coal mine. The reasons for the struggle were that similar access hurdles such as prior authorizations and step edits were driving up the cost to serve, all while reimbursement on the products was in decline and cost of goods was rising.

With the arrival of the general medicine patent cliff came in late 2016, the profitable generic wave machine ended. And adding insult to injury, the government's CPI-U penalty to the generics started on Jan. 1, 2017, effectively ending the ability for generics to increase price after their initial race to the bottom for the first 18 months post-generic launch. We were concerned that this problem could spiral out of control, and we were the only firm talking about this online and on the industry conference stage. In fact, I presented this problem at the Informa Connect Trade & Channel Strategies meeting, which I’ve spoken at for the last 18 years. People in the audience had a look on their faces as if they had no idea what I was speaking about. Unfortunately, our fears and concerns were realized.

Over the past eight years, the situation has not only intensified but has also expanded to include regular branded drugs that were once readily available at every retail pharmacy across the country. Currently, there are about 4,400 branded prescription drugs that comprise a mere 1.5% of all prescriptions dispensed by retail pharmacies. The other 100 brands account for another 6.5% of all prescriptions, with the remainder being generics.

We’ve tried shaking and waking up industry to alert them to the problem. I’d have conversations with retail pharmacy leaders asking us to help educate pharma about the problem. None of the other industry pundits picked up on the gravitas of the situation. And when the direct and indirect renumeration fees went from the back end of the prescription adjudication and reimbursement process, we knew it was going to be like throwing a bucket of gas on an already burning fire.

I credit writing this series for making me realize that, in fact, this started long before specialty lite and the patent cliff. A key event that marked a shift in the classic insurance-based retail pharmacy market (see Figure 1 below) was the reintroduction of cash pharmacy back in 2006 with Walmart’s $4 generics. Most other major retailers followed suit. When 2011 rolled around and we witnessed the launch of GoodRx, I honestly didn’t think much of it. My eye was off the generic ball. I was centered on brands and mainly specialty brands at that. What GoodRx did in hindsight was democratize the prescription. It was the first tool a consumer could use to shop pharmacies and prices. For generics, this was a big deal. Two years after the patent cliff in 2018, the e-commerce pharmacy landscape changed dramatically with the arrival of Amazon Pharmacy, followed by its acquisition of PillPack. Arguably the pandemic masked this issue for a couple years from 2020 to 2022 until the shark-tank minded Mark Cuban’s Cost Plus Drugs further disrupted the market in 2022. 

From 2015 through current day, we have seen the increasing prevalence of digital pharmacies, which many manufacturers hoped would function like specialty pharmacies for retail. That model, however, hasn’t proven to deliver any better net revenue effect than retail from the data points we’ve studied with clients. It’s an alternative, but not necessarily a better one. Then, in the 2020 timeframe, came the emergence of tech-enabled hubs, a retail affordable solution that works somewhat like the patient services platforms used for specialty.

So the crux of my series on “Who Moved My Prescription?” parities the dilemma in the 1990s book 

 in which every day the mouse comes out of the hole and gets the same cheese, and without explanation, one day, the cheese is simply not there. If everything was working fine, the likes of Eli Lilly and Pfizer wouldn’t be launching direct-to-patient models. And now we are contending with telehealth/ecommerce/cash models that we refer to as lifestyle pharmacies, such as Ro and Hims/Hers. The illustration alluded to above shows the chaos and complexity of the current state of retail.

Today, we’re seeing vastly different approaches and perspectives on the profession of pharmacy, and it’s clear that neither the industry nor drug manufacturers know exactly where to turn. The old guard is trying to reinvent themselves a little too late, and the new guard is hoping to come in and blow it all up. Many manufacturer leaders are hoping this issue will resolve itself or that a new model will emerge to address these challenges.

From working with more than 450 manufacturers, we get a unique view of the industry and we see that branded Rx makers are left with a puzzle. It’s not about signaling the downfall of retail, the rise of e-commerce, or the increasing prominence of cash. Nor is it about promoting new pharmacy models.

Over the three decades I’ve been in this industry, we have taken pharmacies for granted. I’ve actually heard retail pharmacy called a “dumb pipe.” We focused on the science, the doctors, the payers, and the patients. We cared about specialty pharmacy because we could see the prescription journey and tie that back to our own patient services platforms. Specialty was cool. Retail was and is a black box.

So where do we go from here? We educate ourselves. We listen. We seek to understand. We try new things. We experiment. We educate management teams, boards, and investors. We reinvent.

Thank you for sticking with me throughout this series. I’ve learned and reflected a lot in the process. I’m excited to share there I’ve been invited back for another series in 2025; there are still a few more topics that need our attention.

Why this trend is occurring and ways that drugmakers are pivoting in order to remedy the situation.

Who Moved My Prescription? Part VI: Abandonment of Branded Prescriptions

On June 27, 2024, Walgreens announced that it was reviewing 2,100 of its 8,600 pharmacies in the US for performance and likely closing of 700 to 800 pharmacies. CVS—which reported that it had 9,939 stores in 2021—has closed almost 700 since then. The company now has 9,273 stores, and plans to close another 300 in 2024. Rite Aid, in 2021, had 2,447 stores and now has 1,704, according to the organization's latest reports.

While independents are holding on at 19,400 stores, according to the National Community Pharmacy Association, as many as a third of them are either planning to close their pharmacies or converting to non-insurance cash-pay pharmacies and focusing on generics.

Several factors have contributed to the wave of pharmacy store closings across the US.

. Reduced reimbursement rates from insurance companies—mixed with rising labor costs, store theft, rising cost of goods, and the high cost of maintaining a brick-and-mortar presence—have made it difficult for many pharmacies to stay afloat.

What’s bad for one may be good for another. Companies such as Amazon Pharmacy; Mark Cuban Cost Plus Drugs; Alto Pharmacy; Capsule; lifestyle pharmacies such as Hims, Hers, Roman, and Lemonaid; cash pharmacies including Blueberry and Eagle; and multi-model pharmacies such as OneroRx and others have come forward to disrupt the world of high-volume, low-cost generic brick-and-mortar pharmacy.

The rise of these new forms of pharmacies and prescription services have changed consumer behavior and reduced foot traffic to physical pharmacy stores. This shift has been accelerated by the COVID-19 pandemic, as more people turned to online options for their medication needs.

Retail pharmacies have become very lazy over the last 20 years as they have outsourced their interactions with payers to pharmacy services administrative organizations and outsourced their sourcing of product to wholesalers. They are told not to pay attention to the losses on individual products and instead, focus on the all-in number. But that’s not working anymore. Otherwise, we wouldn’t be seeing these store closures.

In recent years, the phenomenon of “pharmacy deserts” has gained increasing attention. A pharmacy desert is an area where residents have limited access to pharmaceutical services and medications due to the absence of nearby pharmacies. This issue has been exacerbated by the closure of numerous pharmacy stores, particularly in rural and low-income urban areas.

The closure of pharmacy stores and the resulting pharmacy deserts have profound implications for public health and community well-being.

Residents in pharmacy deserts often struggle to obtain necessary medications. This lack of access can lead to poor health outcomes, particularly for individuals with chronic conditions such as diabetes, hypertension, and asthma.

 Pharmacy deserts disproportionately affect low-income and minority communities, exacerbating existing health disparities. These populations are already at higher risk for certain health conditions and may have fewer resources to seek alternative sources of medication.

 Limited access to pharmacies can lead to increased healthcare costs. When people cannot access their medications, they are more likely to experience complications that require emergency department visits or hospitalizations, placing additional strain on the healthcare system.

 Pharmacies often provide essential health services beyond medication dispensing, such as immunizations, health screenings, and consultations. The loss of these services can leave significant gaps in community healthcare, particularly in areas with limited access to other healthcare providers.

While the problem of pharmacy deserts is already receiving attention in several states, it doesn’t appear that states can prop up a business model in decline, no matter how savvy it is or how involved policymakers, healthcare providers, and community organizations may get.

. Community organizations and local governments can play a crucial role in identifying and addressing pharmacy deserts. Initiatives such as mobile pharmacies, community health clinics, and partnerships with local businesses can help provide alternative sources of medication and healthcare services.

. It may not be enough to shore up new forms of pharmacy for these geographies. Therefore, battle lines are drawing between brick-and-mortar and mail order/home delivery models. And recall that rural and low-income patients who are likely to be disproportionately affected may not practically be able to access these.

. Sorry, this isn’t real. It’s just the No. 1 response we hear from pharmaceutical manufacturers. It seems logical, but recall that these are the entities that have swelled national drug code blocks from 30 to more than 750 in the last 10 years, the ones that added direct and indirect remunerations to non-Medicare volume and even lowered rates for 2025. With that said, pharmacies believe they won something when National Average Drug Acquisition Cost (NADAC) was implemented for Medicaid, but it hasn’t been the silver bullet they were hoping for. It stemmed some losses but didn’t save pharmacy. From research that Blue Fin Group has conducted in the market in 2023 and 2024, payers are promoting to retailers that unprofitable prescriptions can be sent to the payers’ mail order businesses. So why would the payers solve it? Why not let retail implode and vertically stack the business back to mail order, which is exactly what the payers have been doing in specialty pharmacy with their business, especially in the areas of immunology, neurology, dermatology, and respiratory.

If you look up polypharmacy, the actual definition is a patient who’s on five or more medications. The way I’ve used the word throughout my career is a patient who has access to multiple pharmacies for their medications. It wouldn’t be hard to argue that our industry did this to itself with the rise of specialty pharmacy over the last 20 or so years. In the late 1990s, specialty products didn’t fit retail pharmacy. The products were too expensive, unit demand too little, and they came with costly education, prior authorization support, step edits, reauthorization, and very challenging patient economics. It took a new model of pharmacy to support this. I wonder if that’s what we’re seeing here now in the retail space.

The retail pharmacy market is essentially generics and top-100 brands, but everything else is splintering into direct-to-patient models or one-offs thinking that non-specialty products can be forced to work like specialty.

In a custom analysis, our firm Blue Fin Group has done of all the drug launches since the beginning of 2023, and the verdict at the moment is that despite all the attempts at digital pharmacy or any model that is an end-around to the pharmacy benefits manager model, none prove to be successful. But it is clear that we’re going the wrong direction. We are splintering care. We are creating an environment of mixed insurance and cash business. We are risking contra-indications and drug interactions, let alone adherence to therapies.

In summary, I wish I had better news to share. The reality is that retail pharmacy doesn’t know a way out of this situation. My personal assumption is that pharmacies will seek to improve their cost of goods sold by going direct when and where it makes sense. My firm sees the pharmacies trading data and inventory guarantees and becoming part of limited brick-and-mortar and home delivery networks that operate in concert with tech-enabled hubs. The hope is that these pharmacies would then return to profitability, solve for pharmacy deserts with their own mail order or home delivery models, and strike a balance of working with cash pay pharmacy models to find that new model.

Stay tuned for the next and final column in this six-part series where I wrap it all up for 2024 and set our sights on the hottest topic of 2025.

Bill Roth is the SVP of IntegriChain’s consulting business, which includes Blue Fin Group, a strategy consulting company he started in 2001, and the IntegriChain advisory services business.

Making sense of the accelerating trends and challenges—including store closings, pharmacy deserts, and the rise of polypharmacy.

Who Moved My Prescription? Part V: The Many Layers of Pharmacy Crisis Point

 of this series, I covered what is happening; in 

, I introduced why it’s happening; and in 

 I unpacked why this is a hard problem for the pharmacy to solve on their own with pharmacy benefit managers (PBMs) and wholesalers bundling their reimbursement and cost of goods. In this installment, I open the door to what is likely to occur in the general medicine (non-specialty) part of the pharmacy market as a result of these challenges with pharmacy.

I presented at the National Community Pharmacy Association Multiple Locations meeting in March and was asked where I see retail pharmacy going. My answer was simple: it’s highly likely that it returns to what it looked like before the PBMs got involved—to a cash market. The answer received a standing ovation and even an “amen” from the back of the room.

Let me explain as I’m sure 99% of people will think that I’ve lost my marbles. As noted in prior columns, retail pharmacy has reached a breaking point due to sourcing and reimbursement pressures, with a third of community pharmacies poised to close by mid-year and reimbursement rates at all-time lows, pharmacy deserts on the rise, and stories of pharmacies struggling to service what business they have. 

I was told directly by community pharmacy leadership to tell our pharma clients that community pharmacy is walking away from brands, and we are moving our pharmacies to cash. Based on the hundreds of discussions I have with all flavors of retail pharmacy, I’m confident this is more than threats and conjecture. We see it play out in our primary research, and our manufacturers finally see it in the data. Pharmacies are actively moving away from brands and in many cases stop supporting 90-day fills and return to 30-day. The losses to pharmacy are simply too intense.

Cash pharmacy is nothing new. We’ve seen this since 2004 when Walmart announced the first $4 generics and see it today with Amazon Pharmacy and Mark Cuban's Cost Plus Drug Company. Pharmacies are selling product at their wholesale cost hoping for a $15 mark-up to cover the cost of operations and their professional services.

What is rapidly becoming new, though, is cash pay for brands. My consulting firm, Blue Fin Group, conducted a project for a manufacturer opening a direct-to-patient pharmacy, similar to the recently announced Lilly Direct. The impetus for this move was data reflecting that when the product was covered by the insurance plans, the market was more suppressed than anything. What was bizarre was that the demand for the molecule shot up to 3x the demand for the brand.

So the following notion was considered: As opposed to paying all these discounts to PBMs, great purchasing organizations, and distributors, and then hearing from pharmacies that they still lose money, why don’t we just sell through the cash vehicle? The product could rid itself of prior authorizations and step edits, no more suppressed pharmacy economics, and practically complete control of the price to the patient/consumer. Sounds lovely, doesn’t it?

In my opinion, we have been trying to put the proverbial genie back in the bottle for decades. While I personally think insurance works very well for orphan and rare disease products, we are seeing states push back by capping prices. We see cell and gene therapy products without medical policy being set. Specialty is set to go through its transformation for the balance of the decade, with roughly $240 billion at risk to conversion to biosimilars and specialty generics. But with general medicine already converted to generics for 92% of all prescriptions and pharmacies declining to fill brands due to profit loss, this last market is ripe for disruption back to cash.

PBMs are asking for all-time high rebates if generics are available in the drug class, and national drug code blocks have skyrocketed from about 50 in 2013 to more than 700 in 2024.

And for the novel science that tries their hand at the specialty lite price point, they can expect a rigorous prior authorization and likely relegation to a third- to fifth-line therapy. 

Where brands are not excluded, patient out-of-pocket (OOP) costs have grown alongside an expansion in high deductible plans, which now account for ~30% of commercial lives.

 Given the sharp increase in abandonment above $50 copays,

 manufacturers have been driven to spend ever more, driving down OOP through copay cards and patient assistance programs, while battling copay accumulators and maximizer programs.

Many products in the branded general medicine space are obsessing on how to get a $35 OOP to patients while charging $600 to $800. This game appears to be nearing its end. And with the Inflation Reduction Act and most favored pricing, wholesale acquisition cost reductions, and more on the way, the message from government, commercial payers, and plan sponsors is to stop pricing products high because that’s how you think the game is played. The PCSK9 class was the poster child of that. And it appeared when it came time to launch the CGRPs for migraine, the message was received.

As my wife likes to remind me, everything eventually comes back around. Cash pharmacy is not a new concept. It’s the original form of pharmacy and has continued to exist for at least some portion of patients. That portion is growing.

It’s good to remind ourselves that the presence of PBMs and pharmacy benefits is relatively recent in the scheme of things. The first entities appeared in the 1960s. These original PBMs were founded by pharmacists and initially focused on claims processing while reimbursing pharmacies at their usual and customary cash price; notable examples include PAID Prescriptions founded in 1965 and Pharmaceutical Card System (PCS) in 1969. 

The 1970s and 1980s saw significant shifts with vertical and horizontal integrations, driven by cost-containment strategies allowed by the Employee Retirement Income Security Act. In the 1990s, manufacturers began to acquire PBMs, such as Merck with Medco and Eli Lilly with PCS. However, this model was relatively short-lived with both spinning the PBM back out within 10 years, and with Eli Lilly recouping only a quarter of its purchase price.

The durable, impactful, and now-recognizable model borne out by the 1990s through the 2000s is the vertical integration of PBMs with national pharmacy chains and insurers, or consolidation among all three. This began with Rite Aid’s acquisition of PCS from Eli Lilly in 1998 and Express Scripts’ acquisition of DPS in 1999, but was most notably marked by consolidation a decade later of CVS and Caremark, and Express Scripts and Medco. These moves aligned two of the country’s largest pharmacies with two of the largest PBMs. Concurrently, UnitedHealth clawed back its $11 billion drug benefits business from Medco and consolidated pharmacy management into Optum.

Recall that Medicare was cash up until 2006 when we added Part D via the Medicare Modernization Act. But Medicare is now going through its evolution with a $2,000 OOP cap that comes in 2025. All that sounds great if that patient can find a pharmacy willing to dispense the brands that currently run at $50- to $200-a-month losses on a growing number of branded drugs. Reimbursement is going down and pharmacy costs of goods are going up.

I, and those in my firm, see the science, its value, and its demand being challenged. The GLP-1s are a great example. Great science. Great clinical profile. Benefits appear to be building by the day, and with limited coverage, patients are coming OOP for $900-$1000/month. A majority of patients are already willing to situationally pay cash when it results in short-term cost reduction,

 and pharmacies and manufacturers are realizing that the future of retail pharmacy, cash pay, insurance-based coverage for general medicine brands support is at a crossroads.


1. Performance Drug List - Standard Control for Clients with Advanced Control Specialty Formulary. CVS Caremark. January 2024. 

www.bsu.edu/-/media/www/departmentalcontent/payroll/pdfs/oe-2024/medical---prescirption-plans/p11---performance-drug-list-2024.pdf?sc_lang=en&hash=21B89DC77C0880F3E0224F0EF3291764427B7CF7


2. 2024 National Preferred Formulary Exclusions. Express Scripts. April 1, 2024. 

www.express-scripts.com/files/hub/pdf/formulary/NPF_Preferred_Formulary_Exclusions2024.pdf

3. 2024 Premium Standard Formulary. Optum Rx. January 1, 2024. 

www.optum.com/content/dam/o4-dam/resources/pdfs/guides/formularies/Jan2024_Premium_Standard_Abridged_508.pdf

4. 2023 Employer Health Benefits Survey, Section 5: Market Shares of Health Plans. KFF. December 8, 2023. 

www.kff.org/report-section/ehbs-2023-section-5-market-shares-of-health-plans/

5. The Use of Medicines in the US 2023. IQVIA. May 2, 2023. 

www.iqvia.com/insights/the-iqvia-institute/reports-and-publications/reports/the-use-of-medicines-in-the-us-2023

6. Cook, A.; Kornfield, T.; Gold, Marsha. The Role of PBMs in Managing Drug Costs: Implications for a Medicare Drug Benefit. January 2000. KFF. 

www.kff.org/wp-content/uploads/2013/01/the-role-of-pbms-in-managing-drug-costs-implications-for-a-medicare-drug-benefit.pdf

7. Overland, D. UnitedHealth Brings Back PBMs in House. Fierce Healthcare. June 10, 2011, 

www.fiercehealthcare.com/payer/unitedhealth-brings-back-pbms-house

8. Why 'Cash' Pharmacies are Booming—and What it Means for Health Care. August 24, 2022. 

www.advisory.com/daily-briefing/2022/08/24/cash-pharmacies

9. Rewriting the Script: Independent Pharmacy Trends. 2022 Research Report. Prescryptive, October 10, 2023. 

An analysis of the general medicine portion of the pharmacy market amid ensuing challenges.
