The 2023-24 Economic Report on Pharmaceutical Wholesalers and Specialty Distributors

By Adam J. Fein, Ph.D.
(downloadable PDF file; Released October 2023)

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The pharmaceutical channel has fully recovered from the unprecedented volatility triggered by the COVID-19 pandemic. Pharmacy and healthcare provider markets have now reached or exceeded pre-pandemic levels. U.S. distribution and dispensing channels for prescription drugs, which remained highly resilient throughout the pandemic, have now begun their next stage of evolution.

The largest pharmaceutical wholesalers continue to expand their industry position and strengthen their economic fundamentals. The 2023-24 Economic Report on Pharmaceutical Wholesalers and Specialty Distributors delves into the most crucial commercial, political, financial, and legal forces driving change.

The 2023-24 Economic Report on Pharmaceutical Wholesalers and Specialty Distributors—our fourteenth edition—remains the most comprehensive, fact-based tool for understanding and analyzing the large and growing U.S. pharmaceutical distribution industry. Click here to download a free overview of the 2023-24 report.

The report is researched and written by Adam. J. Fein, Ph.D., one of the world’s leading experts on the drug distribution industry and the author of the influential Drug Channels website. Dr. Fein has synthesized a wealth of statistical data (including 150 data-packed exhibits), research studies, financial information, and his own unique business consulting experience into a definitive, nonpartisan resource.

That’s what makes this report essential reading for pharmaceutical manufacturers, wholesalers, pharmacists, pharmacy owners, hospital executives, pharmacy buyers, benefit managers, managed care executives, policy analysts, investors, consultants, and anyone who wants to understand and benefit from this ever-changing industry.

Our 2023-24 edition contains the most current financial and industry data. As always, we have updated all market and industry data with the most current information available. The report also updates our annual analyses of the strategies, market positions, and executive compensation of the three largest companies: AmerisourceBergen (Cencora), Cardinal Health, and McKesson. We review each wholesaler’s business segments and underlying business profitability, based upon our proprietary economic models. This information allows you to assess differences among the public wholesalers’ business organizations, strategies, and financial performance. Where appropriate, financial data have been restated based on updated disclosures.

The notable new material in this 2023-24 edition includes:

  • New data about commercial pricing and reimbursement for provider-administered biosimilars appears in Section 3.2.2. and Section 6.4.3.
  • A new Section 6.2.2. reviews the evolving specialty pharmacy industry and discusses emerging challenges from direct distribution models that bypass wholesale distribution.
  • A new Section 6.3.2. analyzes the acquisitions of physician practices by corporate entities and private equity firms
  • A new Section 6.5. addresses the Inflation Reduction Act of 2022. In Subsection 6.5.1., we summarize the key provisions of the law that relate to prescription drugs. In Subsection 6.5.2., we analyze the IRA’s likely consequences for wholesalers and the overall pharmaceutical business.
  • We provide updated, expanded, and reorganized data about the following markets:
    • Pharmacy services administrative organizations (Section 2.2.4.)
    • Group purchasing organizations for small pharmacies (Section 2.2.5.)
    • Group purchasing organizations for physician practices (Section 3.3.2.)
    • Material that addresses COVID-19 and its impact on the wholesale channel has been integrated into our analyses throughout the report. However, we have retained and updated Section 6.1.4., which examines the distribution of COVID-19 vaccines and therapeutics.
    • There are 163 exhibits in this 2023-24 edition, compared with 150 in the 2022-23 edition.

    No other report on the market today offers the depth, insight and analysis of the 2023-24 Economic Report on Pharmaceutical Wholesalers and Specialty Distributors.

    Effective August 30, 2023, AmerisourceBergen changed its name to Cencora and began trading under the ticker symbol COR on the New York Stock Exchange. Since this change occurred toward the end of the company’s 2023 fiscal year, we refer to the business as “AmerisourceBergen (Cencora)” in the 2023-24 edition of this report. Beginning with the 2024-25 edition, we will exclusively use the name Cencora.

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    TABLE OF CONTENTS

    Introduction and Guide to This Report

    PREFACE: INDUSTRY TRENDS AND KEY REPORT THEMES

    SECTION I: WHOLESALER AND CUSTOMER INDUSTRY ANALYSIS

    Chapter 1: Industry Overview

    • 1.1. Wholesale Industry Fundamentals
      • 1.1.1. Defining Drug Wholesale Distribution
      • 1.1.2. Full-Line Wholesalers
      • 1.1.3. Specialty Distributors
      • 1.1.4. Regulation and Supply Chain Security
    • 1.2. The Products That Wholesalers Sell
      • 1.2.1. Brand vs. Generic Drugs
      • 1.2.2. Route of Administration and Benefit Coverage
      • 1.2.3. Specialty vs. Traditional Drugs
    • 1.3. Overview of Wholesalers’ Channel Roles
      • 1.3.1. Physical Distribution
      • 1.3.2. Financial Intermediation
      • 1.3.3. Services for Pharmacies, Providers, and Manufacturers
      • 1.3.4. Impact on Pharmacy and Provider Reimbursement
    • 1.4. Industry Participants
      • 1.4.1. Big Three Wholesalers: Revenue and Growth Trends
      • 1.4.2. Specialty Product Distribution Market Share
      • 1.4.3. Other Wholesale Market Participants

    Chapter 2: Channel Role for Retail, Mail, and Specialty Pharmacies

    • 2.1. The Pharmacy Market
      • 2.1.1. Outpatient Dispensing Formats
      • 2.1.2. Pharmacy Market Size and Structure
    • 2.2. Independent Pharmacies
      • 2.2.1. Industry Position and Wholesaler Market Shares
      • 2.2.2. Wholesaler Services for Independent Pharmacies
      • 2.2.3. Franchise Programs and Marketing Groups
      • 2.2.4. PSAOs and the Wholesalers’ Role in the Pharmacy-PBM Relationship
      • 2.2.5. Pharmacy Group Purchasing Organizations and Wholesaler Relationships
      • 2.2.6. Wholesaler Generic Source Programs for Smaller Pharmacies
    • 2.3. Retail Chains and Mail Pharmacies
      • 2.3.1. Wholesale Suppliers to Largest U.S. Pharmacies
      • 2.3.2. Physical Distribution Relationships Between Wholesalers and Retail Chains
      • 2.3.3. Generic Sourcing Relationships Between Wholesalers and Large Pharmacies
    • 2.4 Specialty Pharmacies
      • 2.4.1. Specialty Pharmacy Market Participants
      • 2.4.2. Wholesalers’ Specialty Pharmacies
      • 2.4.3. Wholesalers’ Role in Manufacturer-Defined Limited Specialty Networks
      • 2.4.4. Implications for Wholesalers

    Chapter 3: Channel Role for Physician Offices/Clinics and Hospitals

    • 3.1. The Provider-Administered Drug Market
      • 3.1.1. Outpatient Drug Spending and Sites of Care
      • 3.1.2. The Buy-and-Bill System
      • 3.1.3. Group Purchasing Organizations (GPOs)
      • 3.1.4. Contract Management and Chargebacks
      • 3.1.5. White Bagging and Specialty Pharmacies’ Role for Provider-Administered Drugs
    • 3.2. Provider Reimbursement in the Buy-and-Bill System
      • 3.1.1. Medicare Part B and Average Sales Price
      • 3.2.2. Commercial Health Plans
      • 3.2.3. Patient Cost Sharing
    • 3.3. Physician Offices
      • 3.3.1. Pharmaceutical Purchasing and Distributors’ Services
      • 3.3.2. GPOs for Physician Practices
      • 3.3.3. Specialty Drug Dispensing By Physician Practices
    • 3.4. Hospitals
      • 3.4.1. Pharmaceutical Purchasing and Wholesalers’ Services for Hospitals
      • 3.4.2. Hospital GPOs
      • 3.4.3. Specialty Pharmacies at Hospitals and Health Systems
      • 3.4.4. Wholesalers and the 340B Drug Pricing Program

    SECTION II: BUSINESS ECONOMICS AND INDUSTRY TRENDS

    Chapter 4: Wholesaler Profitability

    • 4.1. Sources of Wholesaler Gross Profits and Gross Margin
    • 4.2. Components of Buy-Side Gross Margin
      • 4.2.1. Distribution Service Agreements
      • 4.2.2. Payment Discounts
      • 4.2.3. Specialty Distribution Service Agreements
      • 4.2.4. Generic Sourcing Formularies
      • 4.2.5. Provider-Administered Biosimilars
      • 4.2.6. Wholesaler Compensation and Bona Fide Service Fees
    • 4.3. Sell-Side Gross Margins and Cost-Minus Discounts
    • 4.4. Gross Margins
      • 4.4.1. Overall Gross Margins
      • 4.4.2. Estimates of Buy-Side and Sell-Side Gross Margins
    • 4.5. Gross Profits of Brand, Biosimilar, and Generic Drugs
      • 4.5.1. Lifecycle Profits for Traditional Generic Drugs
      • 4.5.2. Lifecycle Profits for Provider-Administered Generic Drugs
      • 4.5.3. Private Label Generic Drugs
    • 4.6. The Profit Impact of Brand-Name Drug Price Inflation
      • 4.6.1. Brand-Name Drug Inflation and Wholesaler Fees
      • 4.6.2. Inventory Appreciation and Revaluation
    • 4.7. Operating Expenses and Operating Profit

    Chapter 5: Financial Stability and Cash Management

    • 5.1. Debt, Coverage, and Liquidity Ratios
    • 5.2. Balance Sheet Assets
    • 5.3. Cash Conversion Cycle
      • 5.3.1. Inventory Levels and Days Sales in Inventory
      • 5.3.2. Accounts Receivable and Days Sales Outstanding
      • 5.3.3. Accounts Payable and Days Payable Outstanding
    • 5.4. Capital Deployment and Uses of Cash
    • 5.5. Return on Invested Capital
    • 5.6. Stock Market Performance
    • 5.7. Executive Compensation

    Chapter 6: Forces of Change for Drug Distribution

    • 6.1. Industry Outlook
      • 6.1.1. The Outlook for the U.S. Pharmaceutical Market and Wholesaler Revenues
      • 6.1.2. The Outlook for Brand-Name Drug Prices
      • 6.1.3. The Outlook for Generic Drug Prices
      • 6.1.4. Distribution of COVID-19 Vaccines and Therapeutics
      • 6.1.5. Impact of the National Opioid Settlement
    • 6.2. Future Trends for Pharmacy Dispensing Channels
      • 6.2.1. Impact of Pharmacy Market Evolution
      • 6.2.2. Specialty Pharmacy Growth and Challenges from Direct Distribution
      • 6.2.3. The Growth of Specialty Generic Drugs
      • 6.2.4. Importation From Canada
    • 6.3. Future Trends for Buy-and-Bill Channels
      • 6.3.1. Hospital Vertical Integration into Physician Practices
      • 6.3.2. Physician Acquisitions by Corporate Entities and Private Equity
      • 6.3.3. Channels for Cell and Gene Therapies
    • 6.4. The Impact of Biosimilars on Wholesalers
      • 6.4.1. 2023 Update on the Biosimilar Market
      • 6.4.2. Biosimilars Under the Pharmacy Benefit
      • 6.4.3. Biosimilars Under the Medical Benefit
    • 6.5. The Inflation Reduction Act of 2022
      • 6.5.1. Key Provisions of the IRA for Medicare Parts B and D
      • 6.5.2. Wholesale Industry Implications of the Inflation Reduction Act

    SECTION III: BIG THREE WHOLESALER PROFILES

    Chapter 7: Cencora (AmerisourceBergen Corporation)

    • 7.1. Business Overview
      • 7.1.1. Company Information
      • 7.1.2. Company History
      • 7.1.3. Acquisitions and Divestitures
      • 7.1.4. Business Segments
    • 7.2. Profitability
      • 7.2.1. Overall Pharmaceutical Distribution
      • 7.2.2. Profitability by Business Sub-Segment
    • 7.3. Customers
      • 7.3.1. Top 10 Largest Customers
      • 7.3.2. Walgreens Boots Alliance
      • 7.3.3. Express Scripts
    • 7.4. Growth Trends
      • 7.4.1. Distribution Company Growth Trends
      • 7.4.2. MWI Animal Health
      • 7.4.3. Alliance Healthcare

    Chapter 8: Cardinal Health

    • 8.1. Business Overview
      • 8.1.1. Company Information
      • 8.1.2. Company History
      • 8.1.3. Acquisitions and Divestitures
      • 8.1.4. Business Segments
    • 8.2. Profitability
      • 8.2.1. Overall Pharmaceutical Distribution
      • 8.2.2. Profitability by Business Sub-Segment
    • 8.3. Customers
      • 8.3.1. Top 10 Largest Customers
      • 8.3.2. CVS Health
      • 8.3.3. OptumRx
    • 8.4. Growth Trends
      • 8.4.1. U.S. Distribution Growth Trends
      • 8.4.2. Specialty Solutions

    Chapter 9: McKesson Corporation

    • 9.1. Business Overview
      • 9.1.1. Company Information
      • 9.1.2. Company History
      • 9.1.3. Acquisitions and Divestitures
      • 9.1.4. Business Segments
    • 9.2 Profitability
      • 9.2.1. Overall Distribution
      • 9.2.2. Profitability by Business Sub-Segment
    • 9.3. Customers
      • 9.3.1. Top 10 Largest Customers
      • 9.3.2. CVS Health
      • 9.3.3. Rite Aid
    • 9.4. Growth Trends
      • 9.4.1. U.S. Drug Distribution Growth Trends
      • 9.4.2. McKesson’s Specialty Businesses
      • 9.4.3. McKesson Europe
      • 9.4.4. McKesson Canada

    Acronyms and Abbreviations

    Endnotes

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    LIST OF EXHIBITS

    Exhibit 1: Full-Line Wholesale Revenues, by Type of Customer, 2021
    Exhibit 2: Full-Line Wholesalers, Inventory Levels vs. Product Sales, by Product Type, 2021
    Exhibit 3: Full-Line Wholesalers, Inventory Levels and Product Sales, by Product Type, 2011 vs. 2021
    Exhibit 4: Specialty Distributor Revenues, by Customer Type, 2021
    Exhibit 5: Specialty Distributor Sales, by Therapeutic Area, 2021
    Exhibit 6: Average Number of Manufacturers with Distribution Agreements for Specialty Distributors, 2015 to 2021
    Exhibit 7: Distribution Center Operational Metrics, Full-Line Wholesalers vs. Specialty Distributors, 2021
    Exhibit 8: Timeline of DSCSA Requirements for Wholesale Distributors, 2013 to 2024
    Exhibit 9: Unbranded and Branded Generics, Share of U.S. Prescriptions, 2003 to 2022
    Exhibit 10: Allowance for Doubtful Accounts at Big Three Wholesalers, by Company, 2022/2023
    Exhibit 11: U.S. Drug Distribution and Related Revenues at Big Three Wholesalers, Calendar Year 2022
    Exhibit 12: Big Three Wholesalers, Market Share for U.S. Drug Distribution and Related Revenues, 2012 vs. 2022
    Exhibit 13: U.S. Drug Distribution and Related Revenues, Big Three Wholesalers, 2019 to 2023E
    Exhibit 14: Change in Quarterly U.S. Drug Distribution and Related Revenues, Big Three Wholesalers, 2019 to 2023
    Exhibit 15: Specialty Product Distribution Revenues, by Division and Parent Company, 2022
    Exhibit 16: The U.S. Pharmacy Distribution and Reimbursement System for Patient-Administered, Outpatient Brand-Name Drugs
    Exhibit 17: Total U.S. Pharmacy Industry Revenues, Prescriptions, and Locations, by Dispensing Format, 2022
    Exhibit 18: Independent Pharmacy Purchasing Source, by Product Type, 2020
    Exhibit 19: Number of Independent Pharmacy Locations, 2001 to 2022
    Exhibit 20: Independent Pharmacies as a Percentage of Full-Line Wholesaler Revenues, 2014 to 2023E
    Exhibit 21: Independent Pharmacies, Average Per-Prescription Gross Profits and Margins, 2017 to 2021
    Exhibit 22: U.S. Pharmacy Franchise and Marketing Programs, 2023
    Exhibit 23: U.S. Pharmacy Franchise Locations, by Company, 2015 to 2023
    Exhibit 24: Customer Satisfaction with Pharmacies, by Dispensing Format and Company, 2023
    Exhibit 25: Largest Pharmacy Services Administrative Organizations, by Membership and Ownership, 2023
    Exhibit 26: Pharmacy Buying Groups and Primary/Preferred Wholesaler Relationships, by Number of Pharmacies, 2023
    Exhibit 27: Wholesaler Generic Source Programs, Number of SKUs and Manufacturers, 2011 to 2021
    Exhibit 28: Largest U.S. Pharmacies and Their Primary Wholesale Suppliers, 2023
    Exhibit 29: Full-Line Wholesaler Sales to Retail Chain Warehouses, 2007 to 2021
    Exhibit 30: Share of U.S. Generic Purchasing Volume, by Organization, 2023
    Exhibit 31: Pharmacy Locations with Specialty Pharmacy Accreditation, by Corporate Ownership, 2022
    Exhibit 32: Specialty Drug Prescription Revenues, by Dispensing Format, 2022
    Exhibit 33: Prescription Revenues and Market Share from Specialty Pharmaceuticals, by Company, 2022
    Exhibit 34: Participation in Exclusive Specialty Pharmacy Networks, by Company, 2022
    Exhibit 35: Alternative Channels to Specialty Pharmacies in Limited Dispensing Networks
    Exhibit 36: Medical Benefit Spending on Outpatient Provider-Administered Drugs, by Drug Category and Payer, 2021
    Exhibit 37: Spending for Outpatient Medical Benefit Drugs, by Site of Care and Payer, 2021
    Exhibit 38: Medicare Advantage Spending for Outpatient Provider-Administered Drugs, by Site of Care and Drug, 2021
    Exhibit 39: Commercial Medical Benefit Spending for Outpatient Provider-Administered Drugs, by Site of Care and Drug, 2021
    Exhibit 40: Quarterly Health Services Utilization as Percentage of Pre-Pandemic Baseline, 2020 to 2022
    Exhibit 41: Total Drug Purchases by Hospitals and Clinics, 2018 to 2022
    Exhibit 42: Buy-and-Bill System for Distribution and Reimbursement of Provider-Administered Outpatient Drugs
    Exhibit 43: Primary Roles of Third-Party Payer, Distributor, and Provider in Buy-and-Bill System
    Exhibit 44: Chargebacks as a Percentage of Net Sales, Full-Line Wholesalers, 2009 to 2021
    Exhibit 45: White Bagging Approach for Distribution and Reimbursement of Provider-Administered Outpatient Drugs
    Exhibit 46: UnitedHealthcare, White Bagging Requirements for Hospital Outpatient Providers, by Specialty Pharmacy, 2023
    Exhibit 47: Drug Sourcing for Infused Oncology Therapies, by Practice Type and Source, 2019 to 2023
    Exhibit 48: Distribution of Medicare Part B Add-on Payments, 2021
    Exhibit 49: Reimbursement Method for Provider-Administered Drugs Paid Under the Commercial Medical Benefit, by Site of Care
    Exhibit 50: Reimbursement Rate and Administration Cost for Provider-Administered Drugs Paid Under the Commercial Medical Benefit, by Site of Care, 2022
    Exhibit 51: Reimbursement Method for Biosimilars of Provider-Administered Drugs Paid Under the Commercial Medical Benefit, 2021
    Exhibit 52: Commercial Medical Benefit Cost per Claim for Outpatient Herceptin and Its Biosimilars, by Site of Care, 2021
    Exhibit 53: Site-of-Care Management Programs, Commercial Health Plans, 2017 to 2021
    Exhibit 54: Cigna Healthcare, Number of Specialty Drugs Subject to Site-of-Care Medical Policy, 2018 to 2023
    Exhibit 55: Share of Commercial Plan Sponsors Receiving Specialty Drug Rebates, Pharmacy vs. Medical Benefits, 2022
    Exhibit 56: Patient Cost Sharing for Provider-Administered Drugs, 2021
    Exhibit 57: Most Important Service Offered by Community Practice GPOs
    Exhibit 58: Specialty Physician Practice GPOs and Ownership, 2023
    Exhibit 59: Share of Oncologists in Practices with Medically Integrated Dispensing, by Practice Setting, 2010 to 2022
    Exhibit 60: U.S. Hospitals, by Type and Ownership, 2021
    Exhibit 61: Share of Community Hospitals, by Health System Affiliation, 1991 to 2021
    Exhibit 62: Hospital Mergers & Acquisitions, Total Transacted Revenue, 2011 to 2023
    Exhibit 63: Ten Largest Integrated Delivery Networks, by Net Patient Revenues, 2022
    Exhibit 64: Hospital Operating Expenses, by Type of Expense
    Exhibit 65: Change in Hospital Drug Expense per Adjusted Discharge, 2020 to 2023
    Exhibit 66: Ten Hospitals with Largest Pharmacy Expenses, 2022
    Exhibit 67: Number and Share of Pharmacists Employed by Hospitals, 2012 to 2022
    Exhibit 68: Number of Inpatient Pharmacists and Pharmacy Technicians per 100 Occupied Hospital Beds, 2002 to 2022
    Exhibit 69: Largest Group Purchasing Organizations, by Membership and Total Purchasing Volume, 2023
    Exhibit 70: Hospitals with a Specialty Pharmacy, by Number of Staffed Beds, 2015 to 2022
    Exhibit 71: Hospital and Clinic Share of Oral Oncology Market, 2017 to 2022
    Exhibit 72: 340B Drug Pricing Program, Purchases by Covered Entities, 2015 to 2022
    Exhibit 73: Key Elements on a Wholesaler’s Income Statement
    Exhibit 74: Sources of a Wholesaler’s Gross Margin from Brand-Name Drugs
    Exhibit 75: U.S. Drug Distribution Gross Margin, Big Three Wholesalers, 2019 to 2023
    Exhibit 76: U.S. Drug Distribution Gross Profits, Big Three Wholesalers, Total and Annual Change, 2019 to 2023
    Exhibit 77: Estimated Buy-Side and Sell-Side Contributions to Wholesalers’ Gross Margin, 2023
    Exhibit 78: Estimated Drug Distribution Gross Margin, by Drug and Customer Type, 2023
    Exhibit 79: Big Three Wholesalers, Revenues and Gross Profits, by Type of Drug, 2023
    Exhibit 80: Median Wholesaler Sell-Side Discount for Generic Drugs Sold to Retail Pharmacies, by Number of Manufacturers, 2023
    Exhibit 81: Path of Wholesaler Gross Profits, Brand vs. Multi-Source Generic Drug, 2021
    Exhibit 82: Brand-Name Drugs, Change in Average List and Net Prices, 2014 to 2023
    Exhibit 83: Illustrative Value of a Wholesaler’s Buy-Side Fees with Alternative Brand-Name Pharmaceutical Price Inflation Scenarios
    Exhibit 84: Price Indices for Warehousing & Storage and Truck Transportation, 2019 to 2023
    Exhibit 85: Illustrative Effect of Inventory Revaluation on a Wholesaler’s Gross Profit
    Exhibit 86: Full-Line Wholesalers, Operating Expenses, by Category, 2021
    Exhibit 87: Median Annual Total Employee Compensation, by Company, 2022
    Exhibit 88: Big Three Wholesalers, Drug Distribution Operating Profit as a Percentage of Revenues, 2019 to 2023
    Exhibit 89: Big Three Wholesalers, Distribution Operating Profits as a Percentage of Gross Profits, 2023
    Exhibit 90: Big Three Wholesalers, Total Debt Including Interest Payments, 2023
    Exhibit 91: Big Three Wholesalers, Debt-to-EBITDA Ratio, FY2021 to FY2023
    Exhibit 92: Big Three Wholesalers, Liquidity Ratios, FY2023
    Exhibit 93: Big Three Wholesalers, Composition of Current Assets, 2023
    Exhibit 94: Illustrative Wholesaler Cash Conversion Cycle for Brand-Name Drugs Sold to a Pharmacy
    Exhibit 95: Big Three Wholesalers, Cash Conversion Cycle, 2023
    Exhibit 96: Big Three Wholesalers, Cash Conversion Cycle, 2013 to 2023
    Exhibit 97: Big Three Wholesalers, Days Sales in Inventory, 2019 to 2023
    Exhibit 98: Wholesalers’ Days Sales in Inventory, by Therapeutic Category, 2022
    Exhibit 99: Big Three Wholesalers, Days Sales Outstanding, 2019 to 2023
    Exhibit 100: Percentage of Wholesalers’ Trade Accounts Receivable and DSO for Largest Customers, 2023
    Exhibit 101: Big Three Wholesalers, Days Payable Outstanding, 2019 to 2023
    Exhibit 102: Big Three Wholesalers, Capital Deployment, FY2019 to FY2023
    Exhibit 103: Big Three Wholesalers, Dividends and Share Repurchases as a Percentage of Operating Cash Flow, FY2021 to FY2023
    Exhibit 104: Big Three Wholesalers, Return on Invested Capital, 2016 to 2023
    Exhibit 105: Forward Price-to-Earnings Ratio, Big Three Wholesalers vs. S&P 500, 2014 to 2023
    Exhibit 106: One- and Five-Year Stock Price Performance, Big Three Wholesalers vs. Manufacturers and Overall Market
    Exhibit 107: Components of CEO Compensation, Big Three Wholesalers, 2022/23
    Exhibit 108: Financial Metrics Used for Annual Cash Incentive Compensation, Big Three Wholesalers, 2022/23
    Exhibit 109: Financial Metrics Used for Long-Term Incentive Compensation, Big Three Wholesalers, 2022/23
    Exhibit 110: Annual Change in Manufacturer Revenues, List vs. Net Prices, 2017 to 2027
    Exhibit 111: Total Manufacturer Net Brand Revenues Lost to Generic Launches, by Product Type, 2017 to 2027
    Exhibit 112: U.S. Drug Distribution and Related Revenues, Big Three Wholesalers, 2017 to 2027
    Exhibit 113: Average Year-over-Year Change in Pricing of Mature Generic Drugs, Oral vs. Injectable, 2015 to 2023
    Exhibit 114: Generic Drug Approvals, FDA, 2014 to 2023
    Exhibit 115: Pharmacy Industry Prescription Revenues, Traditional vs. Specialty Drugs, 2017 to 2027
    Exhibit 116: Top Specialty Therapy Categories, Generic Drugs as a Share of Prescriptions and Net Spending, 2020
    Exhibit 117: Nonbiological Specialty Drugs, Pharmacy Acquisition Cost per Unit for Brand-Name vs. Generic Version, 2023
    Exhibit 118: Physician Employment, by Practice Ownership, 2012 vs. 2022
    Exhibit 119: Number of Physicians per Practice, by Practice Ownership, 2022
    Exhibit 120: U.S. Physician Employment, by Specialty and Employer Type, 2022
    Exhibit 121: Number of U.S. Physicians Employed by Hospitals/Health Systems, 2019 to 2022
    Exhibit 122: Acquisitions of Community Oncology Practices, by Type of Acquirer, 2010 to 2022
    Exhibit 123: Medicare Part B Spending on Provider-Administered Outpatient Drugs, by Location of Service, 2008 to 2021
    Exhibit 124: Share of Medicare Part B Spending on Provider-Administered Outpatient Drugs, by Location of Service, 2008 to 2021
    Exhibit 125: Share of Specialty Distributor Revenues, by Customer Type, 2011 to 2021
    Exhibit 126: Vertical Business Relationships Among Insurers, PBMs, Specialty Pharmacies, and Providers, 2023
    Exhibit 127: Number of Private Equity Acquisitions of Physician Practices, 2013 to 2022
    Exhibit 128: Certified CAR-T Centers, by Products, 2019 vs. 2022
    Exhibit 129: Pricing and Payments for CAR-T Therapies, Commercial Health Plans, 2021
    Exhibit 130: Number of U.S. Biosimilar Approvals, 2015 to 2023
    Exhibit 131: Approved Biosimilars of Humira, Price and Negotiated Launch Date, 2023
    Exhibit 132: Insulin Glargine, Share of New-to-Brand Prescriptions, 2022
    Exhibit 133: FDA-Approved Biosimilars, Provider-Administered Drugs, 2015 to 2023
    Exhibit 134: Market Share of Provider-Administered Biosimilars, 2023
    Exhibit 135: Provider-Administered Oncology Drugs, Prices of Biosimilars vs. Reference Product, 2023
    Exhibit 136: Physician Perceptions of Biosimilars, by Specialty, 2023
    Exhibit 137: Standard Medicare Prescription Drug Benefit, 2022 vs. 2025
    Exhibit 138: AmerisourceBergen (Cencora), Pharmaceutical Distribution Segment, Profitability Metrics, 2019 to 2023
    Exhibit 139: AmerisourceBergen (Cencora), Estimated Revenues and Operating Profit, by Segment, FY2023E
    Exhibit 140: AmerisourceBergen (Cencora), Top 10 U.S. Drug Distribution Customers, FY2023
    Exhibit 141: AmerisourceBergen (Cencora), Revenues from Walgreens Boots Alliance, 2014 to 2023
    Exhibit 142: AmerisourceBergen (Cencora), Days Sales Outstanding from Walgreens and Express Scripts vs. All Other Customers, 2019 to 2023
    Exhibit 143: AmerisourceBergen (Cencora), Revenues from Express Scripts, 2014 to 2023
    Exhibit 144: Express Scripts, Pharmacy Dispensing Revenues vs. Pharmaceutical Purchases Through AmerisourceBergen (Cencora), 2014 to 2023
    Exhibit 145: AmerisourceBergen (Cencora), U.S. Pharmaceutical Distribution, Revenues and Growth, 2019:Q1 to 2023:Q2
    Exhibit 146: MWI Animal Health, Revenues and Growth, 2019 to 2023
    Exhibit 147: Animal Health Products Distribution Market Share, by Company and Segment, 2014 vs. 2023
    Exhibit 148: Number of Pharmacies, Major European Countries, 2022
    Exhibit 149: Cardinal Health, Profitability Metrics, 2019 to 2023
    Exhibit 150: Cardinal Health, Estimated Revenues and Operating Profit, by Segment, FY2023
    Exhibit 151: Cardinal Health, Top 10 U.S. Drug Distribution Customers, FY2023
    Exhibit 152: Cardinal Health, Revenues from CVS Health, 2010 to 2023
    Exhibit 153: Cardinal Health, Days Sales Outstanding from CVS Health and OptumRx vs. All Other Customers, 2019 to 2023
    Exhibit 154: Cardinal Health, Revenues from OptumRx, 2016 to 2023
    Exhibit 155: Cardinal Health, U.S. Pharmaceutical Distribution, Revenues and Growth, 2019:Q1 to 2023:Q2
    Exhibit 156: McKesson, Distribution Businesses, Gross and Segment Operating Profitability Metrics, 2019 to 2023
    Exhibit 157: McKesson, Estimated Revenues and Operating Profit, by Segment, FY2023
    Exhibit 158: McKesson, Top 10 U.S. Drug Distribution Customers, FY2023
    Exhibit 159: McKesson, Revenues from CVS Health, 2011 to 2023
    Exhibit 160: McKesson, Days Sales Outstanding, CVS Health vs. All Other Customers, 2019 to 2023
    Exhibit 161: McKesson, Revenues from Rite Aid, 2019 to 2023
    Exhibit 162: McKesson, U.S. Pharmaceutical Distribution, Revenues and Growth, 2019:Q1 to 2023:Q2
    Exhibit 163: McKesson Canada, Revenues and Growth, 2019 to 2023

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