AMZN: How to enter (and ultimately dominate) pharmacy

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SEE END OF THIS REPORT FOR IMPORTANT DISCLOSURES

Healthcare: Richard Evans / Scott Hinds
203.901.1631 /.1632
revans@ / shinds@ssrllc.com
@SSRHealth

TMT: Paul Sagawa / Tejas Raut Dessai
203.901.1633 /.553.9827 psagawa@ / trdessai@ssrllc.com
@PaulSagawaSSR
November 5, 2017

AMZN: How to enter (and ultimately dominate) pharmacy

AMZN’s history in e-commerce has been that of manifest destiny, methodically moving category by category, applying its logistics mastery and relentless focus on customer experience to erode incumbent retailers and distributors. To that end rumors that AMZN is eying the drugstore/pharmacy market ($270B US, $500B Global) as its next frontier are credible. Adding this untapped category would have substantial synergies with its local delivery and grocery strategy, and could strengthen the Prime program for existing members while attracting new ones. From the outside, we believe that a winning strategy for AMZN’s market entry could take the following approach: 1. Implement a superior interface, customer service and delivery system for consumers integrating delivery, physical stores (e.g. Whole Foods), and affiliates; 2. Win over benefit providers not already committed to their own delivery operations, levering superior service and efficiency; 3. Acquire proven specialty pharmacy service capacity and contracts; 4. Lever superior experience for consumers and prescribers to pull support from upstream players. Each of these strategic objectives have specific underlying tactical steps that we believe could position AMZN to gain critical mass in pharmacy and eventually transform it.

  • Don’t buy a PBM. It limits your share of dispensing to your share of covered lives, and puts you in the position of having to tell customers what they can and cannot have
  • Offer mail fulfillment to benefit providers whose profits are not dominated by their own mail operations, and whose strategic interests include advancing customer service levels at pharmacy (e.g. UNH/OptumRx, HUM, ANTM, MedImpact, CI). Produce immediate savings by shrinking dispensing margins on generics at mail; produce immediate service level gains by helping customers find the most affordable dispensing option, and by making best use of packaging and compliance tech (see later)
  • Acquire proven specialty pharmacy service capacity, and contracts. You’ll need specialty pharmacy capacity immediately (faster than it can be created from a standstill); and, buying into a portfolio of agreements that include you as one of a few limited (or as the exclusive) distributor of key specialty products ensures that you’ll be managing (at least specialty) fulfillment for a broad list of benefit managers. DPLO is the logical choice
  • Put pharmacies in Whole Foods locations, bring select independent (high quality / high volume) pharmacies under the Amazon Pharmacy banner (as affiliates, not as owned sites); and, bring prescriptions to Amazon Locker. Consider using your ‘bannered’ independents as anchor points for same day delivery. Think of this more as a compliment to home delivery than as an effort to compete in brick and mortar retail
  • Show me where to get my household’s entire list of prescriptions filled for the lowest possible out-of-pocket cost – even if it’s not with you. Show me how best to use my drug benefit (e.g. should I pay cash for the generic, or the co-pay), and how to make best use of manufacturer coupons and other support programs, all in light of my consumption history and my specific Rx benefits
  • Organize existing innovations and technologies around the prescription consumer, e.g. calendar packs that organize multi-drug regimens into simple formats; smart prescription packs that remind patients when to take meds and alert caregivers / providers when meds are (or are not) taken; ‘gamification’ tech that engages kids in managing their conditions; even technology that proves whether a medication was actually swallowed. If you put every pill I take into a simple calendar pack, I’ll buy every pill (Rx and non-Rx) I take directly from you. Same goes if you can use games to get my daughter to take her asthma meds, or tech to tell me whether my father took his Eliquis today. As a prescriber, do these things for my patients and I’ll encourage them to fill their Rx’s with you
  • For bonus points: Physicians hate their practice management software – which has a module that links directly to pharmacy. Consider developing a new generation practice management platform (or partnering with an innovative 3rd party developer) they will like – that includes an innovative two-way pharmacy module (sends Rx’s, but also receives patient-level info from smart packs, wearables, etc.) that serves everyone’s best interests, and in so doing drives volumes to your dispensing

Here Comes Amazon

In its 20-year history, AMZN has lain waste to bookstores, big box retailers, department stores, discount retailers, sporting goods stores, office supply stores, and a host of smaller retail categories. The company’s approach is methodical. Identify an attractive market segment. Offer customers excellent prices, comprehensive selection, and increasingly convenient shopping and delivery. Lever the Prime membership program to build early volumes in the new category. Lever the new product capability to attract new Prime members. Use world-class logistics, technology and scale economies to establish significant cost and service advantages. Rinse and repeat

Once it has identified a new opportunity, AMZN is patient and may make several attempts to enter using different approaches, ready to pull back if the early performance is less than promising. Eventually, AMZN will feel confident in its strategy and it will strike decisively. Groceries is the obvious example. Amazon Fresh trials in Seattle went on for a few years before it was expended to new markets and then to broader availability. Trials of tech-heavy grab-and-go convenience stores began. Then came the Whole Foods acquisition to accelerate everything. Rumor has it that pharmacies may be next

Like grocery, AMZN has been poking around pharmacy for years. It is an obvious target – a $270B US market (more than $500B globally) – that would seem to fit the company’s core strengths and leverage its existing businesses. As a product, drugs – high value, light weight, not requiring in person choices, and in almost universal demand – are a perfect match. The catch are the obstacles raised by tight government regulation and by an insurance-driven payment system that exerts control over how a consumer might fulfill prescriptions. If AMZN believes that it has a strong plan to traverse these obstacles, the question becomes how AMZN enters

In this context, we see two pertinent questions for investors: 1) how might AMZN enter the current business; and 2) how might AMZN ultimately transform the business? Given the size of the US market – and for simplicity – we’ll restrict our case to the US; however, we believe that if AMZN enters pharmacy it would ultimately do so on a multi-national basis

How AMZN might enter

Not by purchasing a PBM. If AMZN acquires a PBM (e.g. ESRX), then it immediately limits its share of prescription fulfillment to its share of covered pharmacy lives. For example, if OptumRx beats AMZN/ESRX for the GM contract, there’s little chance OptumRx allows AMZN to fill any GM prescriptions. So, while ESRX’ current share of US prescriptions adjudicated is impressive, it falls well short of what we would assume is AMZN’s goal of being the preferred fulfillment arm for everyone. Perhaps more to the point, being a PBM means restricting your customers’ choices, which seems anathema to AMZN’s focus on ‘selection, price, and convenience.’ AMZN famously shows its customers where else they can buy a given product, and for what price; including sellers offering lower prices. PBMs do nothing of the sort

Start with mail fulfillment …

AMZN moves A LOT more product through mail than it does through brick and mortar retail locations; currently the US prescription market moves much more drug through retail than through mail. An immediate challenge is that prescription benefits typically only pay for mail order dispensing from a single source (generally the PBM or HMO’s own captive mail order operation). This raises the question of how AMZN can get paid to dispense prescriptions at mail when most pharmacy benefits are restricted to captive mail order owned or controlled by the benefit manager. Pressing the matter via any willing provider laws is a long and uncertain path given the power of state pharmacy boards, and the preponderance of independent pharmacists (who are plainly threatened by AMZN) on these boards. Pressing major plan sponsors to include AMZN prescription fulfillment is unlikely to succeed before AMZN has significant experience filling prescriptions – an obvious Catch-22. This narrows AMZN’s options to convincing current benefit providers to let AMZN fulfill prescriptions at mail – and this only works in instances where the benefit providers’ interests aren’t dominated by its own mail fulfillment operations[1] (and where such benefit providers are not exclusively committed to existing mail providers)

Sizable benefit providers who might feasibly consider allowing AMZN to fill their prescriptions at mail include OptumRx (UNH), ANTM, HUM, MedImpact, and CI; collectively these providers account for well over 2B prescriptions annually

  • OptumRx (1.2B Rx claims worth $60.4B in 2016) is the captive PBM of UNH, and has its own mail order fulfillment; however, we believe the UNH/Optum mindset is reasonably well-aligned with the AMZN mindset of constantly improving the service offering. As such it seems reasonable to believe that UNH/Optum might see AMZN’s physical fulfillment of UNH/Optum adjudicated prescriptions[2] as a step toward a more competitive service offering. Importantly, plan sponsors considering whether to go with UNH/Optum or its competitors should see AMZN’s inclusion in prescription fulfillment as a positive differentiation
  • HUM (426M Rx claims worth $22B in 2016) has its own captive PBM (Humana Pharmacy Solutions) with its own mail order operation; however, like UNH/Optum, HUM arguably could improve its customer service levels, and its attractiveness to plan sponsors, by using AMZN for mail fulfillment
  • ANTM (220M Rx claims worth $17.1B managed via ESRX in 2016), having split with ESRX, is setting up its own captive PBM (IngenioRx), which launches in 2020. ANTM has partnered with CVS on IngenioRx, and it’s unclear whether CVS has an exclusive lock on ANTM’s mail order fulfillment. If not, ANTM – like UNH/Optum and HUM — arguably would be well served to consider AMZN for mail fulfillment, even if the AMZN mail option is offered alongside a competing CVS/Caremark alternative
  • MedImpact (estimated 327M Rx claims worth $16.5B in 2016) is a privately-held PBM that coordinates – but does not own – either retail or mail order fulfillment. As a mid-sized PBM whose interests are not strategically dominated by ownership of mail fulfillment, and who appears willing to work with multiple mail providers, it’s reasonable to believe that AMZN could provide fulfillment for MedImpact
  • CI ($3.0B in 2016 mail order pharmacy revenues) Cigna Pharmacy Management is CI’s captive PBM which serves approximately 8.5M lives, and whose operations include owned mail order. Like UNH/OptumRx, HUM, and ANTM, CI almost certainly could approve its mail order offering, and its attractiveness to plan sponsors, by involving AMZN in mail fulfillment

Sizable providers who could benefit from AMZN fulfillment but who may be locked into exclusive relationships include Prime Therapeutics and AET

  • Prime Therapeutics (305M Rx claims worth $22.6B in 2016) is a privately-held PBM owned by the Blues plans whose members it serves. Prime recently partnered with WBA to create AllianceRx Walgreens Prime, a ‘combined central specialty pharmacy and mail services company.’ Prime Therapeutics and its Blues owners / customers arguably would be well served by AMZN mail fulfillment; however, as an operator of US retail pharmacies WBA almost certainly does not want to see AMZN in the pharmacy market in any capacity. It’s unclear whether the AllianceRx Walgreens Prime agreement affords Prime Therapeutics the option of including AMZN fulfillment
  • AET ($1.3B in 2016 home delivery / specialty revenues) is an HMO with captive PBM services (Aetna Specialty Pharmacy and Aetna Rx Home Delivery); Caremark is involved in adjudication and fulfillment of claims, and whether this relationship is currently exclusive is unclear. CVS is reportedly attempting to purchase AET

Sizable providers threatened by AMZN’s entry include ESRX and CVS/Caremark. AMZN’s best chances of accessing this prescription volume are longer-term: 1) for HMO’s and PBM’s that use AMZN fulfillment to take share from ESRX and CVS/Caremark; and/or 2) for AMZN to convince plan sponsors their beneficiaries be given the option of AMZN fulfillment, even when ESRX or CVS/Caremark are chosen as benefit managers

  • ESRX (1.1B Rx claims worth $51.4B in 2016) is a stand-alone PBM with an owned mail order pharmacy; beneficiaries for whom ESRX manages benefits generally can only fill prescriptions at mail through ESRX’s owned mail operations. Mail fulfillment is a significant contributor to overall margins; AMZN’s entry stands to raise service levels and reduce margins, and erode ESRX’ share
  • CVS/Caremark (1.2B Rx claims in 2016). CVS operates US retail pharmacies, and its PBM Caremark provides pharmacy benefit management and mail fulfillment through owned mail order operations. AMZN’s entry into pharmacy threatens both the retail and mail operations. Like ESRX, Caremark beneficiaries generally can only fill prescriptions at mail through Caremark’s owned mail order

… add specialty pharmacy capacity and contracts …

More than half of plan sponsors require that specialty pharmaceuticals be filled by a specific pharmacy or group of pharmacies; of these more than two-thirds view mail order specialty pharmacies as the lowest cost means of filling these prescriptions[3]. Growth in specialty drug spending dominates overall prescription benefit spending growth, making management of specialty trend a top priority for plan sponsors

Specialty pharmaceutical products often are available through only a limited number of specialty pharmacy providers, and occasionally are available only through a single, exclusive specialty pharmacy

It logically follows that AMZN needs to offer proven specialty services from the outset. To be a viable option for plan sponsors and benefit managers, AMZN needs to be included as an in-network pharmacy for the major specialty brands that are distributed selectively. And, AMZN would benefit from having exclusive distribution relationships on select specialty brands, as this effectively forces plan sponsors to use AMZN fulfillment, at least for those exclusive brands

After the wholly-owned captive specialty pharmacies controlled by CVS (CVS Caremark Specialty Pharmacy), ESRX (Accredo), WBA (Walgreens Specialty Pharmacy), and UNH (BriovaRx), Diplomat Pharmacy (DPLO) is the largest independent specialty pharmacy ($4.6B in 2016 specialty revenues)[4]. Acquiring DPLO would immediately give AMZN proven specialty pharmacy capacity, as well as existing distribution relationships for both narrowly and exclusively distributed specialty brands

… and finally, develop bricks and mortar locations as compliments to mail order …

Against a US backdrop of +/- 60,000 existing retail pharmacies – about 34% more than are needed – and with major competitors having far larger store counts (WBA +/- 9,500; CVS +/- 9,600), placing pharmacies in AMZN’s +/- 450 Whole Foods locations hardly counts as strategic presence. Nevertheless, Whole Foods can serve as a retail platform on which AMZN might prove its ability to positively redefine customer service levels at the prescription counter (see later) in those stores with enough space to accommodate a pharmacy. Over time AMZN can extend its physical retail presence through partnerships with independent pharmacies (see later) and/or through innovative sites such as Amazon Locker

How AMZN might take over …

The US pharmaceuticals market is a highly complex transaction space driven not only by manufacturers and consumers, but also by family members, prescribers, benefit providers, plan sponsors, and the drug trades (wholesale, retail). Transaction costs generally are high, and service levels often are low – both in absolute terms, and relative to service levels that are achievable with practical levels of effort

When I fill a prescription as a consumer, I don’t know the price my pharmacy is offering unless I ask up front, and I don’t know if my pharmacy’s price is competitive unless I check online sources, whose information is valuable but often out-of-date and/or incomplete. If, like most households, I’m filling multiple prescriptions per month, my task is even harder, since it’s that much tougher to determine which pharmacy will give me the best deal on the entire list of meds

Even if I make the considerable effort to determine – and stay on top of – which pharmacy offers the best prices for my household’s needs, there’s almost no way for me to reliably determine how best to pay for those prescriptions. Should I use my benefit, or pay cash for the generics? (Co-pays for generics often exceed the cash price for the generic). Are there manufacturer co-pay programs for the drugs I’m taking, where are they honored, and can they be used with my prescription benefit? And, if I’m in the deductible period and paying full price, should I use an out-of-benefit discount program, or is the short-term cash savings not justified by the cost of delaying the point at which my drug benefits kick in?

All else equal, any pharmacy that shows me the most cost-effective way of filling my prescriptions – taking account of all relevant factors including retail pricing, availability and applicability of discount programs, my benefits and my consumption history – and, who consistently offers the most cost-effective solution, is likely to get my business. This is very close to what I get for my non-prescription purchases from Amazon Prime

As a family member, I’d really like to know if my father took his Eliquis today. The technology exists to give me (and his physician) this information, but it’s not routinely used

As a prescriber, for that significant subset of patients for whom daily compliance is essential, I’d like to know that they’ve filled their prescriptions on time, and that they’ve taken those medications on time. The technology exists to tell me all of these things, and even to prove to me that the patient swallowed the pill and/or that my patient’s measurable characteristics (blood pressure, blood glucose, cardiac rhythm, etc.) are within acceptable limits. And, for those patients with significant pill burdens, I’m even more concerned to know that they’re consistently taking the right drug at the right time on the right day. The technology exists to dispense to my patients in calendar packs that pre-organize their daily prescriptions, but this technology also is rarely used. Often prescribers rely on patients or family members to organize complex prescription regimens; if physicians could order this service reliably and cost-effectively, it’s reasonable to assume many would

As a benefit provider, I’d like lower costs (e.g. narrowing of generic dispensing margins, especially at mail), would like to know that the drugs dispensed are being consumed (more routine use of compliance monitoring technology; better multi-Rx packaging), and are having the intended effects (more routine use of patient monitoring technology). And, I’d like to offer my plan sponsors and beneficiaries a service level that’s better than what they’re used to, and better than what’s available elsewhere

As a plan sponsor, my interests mirror those of the benefit provider, except that I’d also like to be able to use manufacturer discount programs selectively, where they lower my costs without competing with my health outcomes goals and beneficiary satisfaction goals

This multi-dimensional appetite for better pharmacy service can be met with a combination of hard work and application of existing technologies, and the resulting service level can be advanced even further through continued innovation. Lowering costs can begin with squeezing generic dispensing margins (particularly at mail) and making use of AMZN’s presumably lower shipping costs. Making sure patients take the right drug at the right time starts with better organized packaging (e.g. calendar packs[5]), technologies that actively remind the patient to take a drug at the right time, ‘gamification’ technologies that include patients’ compliance as a variable in digital games[6], technologies that confirm to family members and/or providers that at least the correct package was opened at the right time[7], and in select cases technologies that confirm to caregivers that the drug was in fact swallowed by the patient[8]. Oh, and any of dozens of consumer wearables that monitor any number of relevant patient parameters

Further strategic considerations / options

  • Consider developing a physician practice management (PPM) offering. Physicians’ offices hate – HATE – their (PPM) software and vendors. This is a clear opportunity for Amazon to address via an internally developed platform or through a partnership with a strong 3rd party developer partner. Crucially, PPM software links directly to pharmacy. A two-way module that not only transmits prescriptions to pharmacy, but also receives data streams back from both the pharmacy (e.g. the Rx was dispensed) and the patient (e.g. the Rx was received, opened at the correct times, and actually consumed)
  • Use one of the big three US drug wholesalers. Brand manufacturers generally will not enter into an invoice relationship with a dispensing pharmacy; rather, brand manufacturers prefer to drop ship to the warehousing pharmacies (of which AMZN obviously would be one), then route the invoice through the warehousing pharmacy’s wholesaler. The reason is straightforward – if a pharmacy chain doesn’t pay the manufacturer’s invoice on time, the manufacturer can hardly threaten not to ship the next order to the pharmacy, because the manufacturer simply cannot be out of stock at the end-user level. However, if a wholesaler doesn’t pay the manufacturer’s invoice (on behalf of the warehousing pharmacy) client on time, the manufacturer can cut that wholesalers’ pending orders until the invoice is paid, and in the meantime will instruct that wholesaler’s clients to order through their secondary wholesaler. This means that – at least in the beginning – brand manufacturers are unlikely to ship and invoice AMZN directly, i.e. AMZN almost certainly will need a relationship with one of the big three (ABC, CAH, MCK) wholesalers
  • Elbow your way into global generics purchasing arrangements, if possible. AMZN could benefit by purchasing generics through either of the larger wholesaler / retailer JV’s (WBA/ABC, CVS/CAH, WMT/MCK); however, because these JVs arguably are controlled more by the retail partners than by the wholesalers, AMZN might not be welcomed
  • Beware of the store-in-store model. WBA and/or CVS might logically offer to operate retail pharmacies within Whole Foods on AMZN’s behalf. This extends the chain retailer’s network, and eliminates AMZN/Whole Foods pharmacies as potential price competitors. The downside to AMZN is that they would lose the ability to shape the customer service level and control prices in their pharmacies; the upside is that allowing either chain retailer into Whole Foods would overcome the issue immediately above (it would get AMZN into a generic sourcing JV). Our bet is that AMZN is far more interested in redefining customer service in pharmacy than in sourcing generics more cheaply (at least in the short-term) through any of the existing JV’s; as such we doubt AMZN allows anyone else to set up pharmacies in Whole Foods
  • Love those independents. Independent pharmacies (about 16% of retail Rx dispensing in the US) are at near-term risk of being shuffled out of the deck as payors work hard to narrow retail dispensing networks. The opportunity exists for AMZN to ‘banner’ the best of these stores as a means of expanding its retail pharmacy (and other consumables) footprint, without having to actually acquire the stores. Consumers can order and pay for prescriptions online, and either pick them up at the independent or have them same-day delivered. Your ability to empower independents gives you even more leverage in your wholesale relationship – independents are their most profitable outlets, and whoever doesn’t get your wholesale contract risks losing their independents into your bannered network

Who wins, and who loses

Winners:

  • AMZN is an obvious winner with entrée to another very large and profitable retail market where it can improve customer service, squeeze out inefficiencies, and build loyalty/attract new members to its Prime program. One more major growth vector for a company that already has many
  • Amazon Prime members
  • Benefit providers that improve their customer service at mail, and the attractiveness of their benefit offerings, by bringing AMZN in for mail fulfillment (potentially any of UNH/OptumRx, ANTM, HUM, MedImpact (private), CI)
  • Blue-chip specialty-pharmacy provider(s) potentially acquired as a source of proven capabilities, and to provide access to limited and exclusive-distribution products (most logical candidate is DPLO)
  • Innovators in medication compliance technology (virtually all of whom are private, see footnotes 3 thru 8)
  • Whichever of the big three US drug wholesalers is chosen as the intermediary between AMZN and brand manufacturers (ABC, CAH, or MCK)
  • Select independent pharmacies in the event AMZN expands its retail network by ‘bannering’ independents

Losers:

  • Retail pharmacies other than those select independents that might be ‘bannered’ by AMZN (CVS, WBA, RAD, FRED); expect downward pressure on dispensing margins, upward pressure on customer service levels and associated costs, shift of dispensing share towards AMZN mail and/or AMZN physical sites (Whole Foods, bannered independents, alternative sites such as Amazon Locker)
  • PBMs that rely largely on pharmacy benefit carve-outs (ESRX, CVS/Caremark), since an AMZN entry makes it that much easier for HMOs to reintegrate the pharmacy and medical benefits. (With AMZN an HMO can reliably commit to meet or exceed the service levels offered by the stand-alone PBMs, without having to face the prospect of building and operating the specialty and home distribution components of the offering)
  • PBM with captive mail order that accounts for a substantial percentage of gross profits (ESRX); expect loss of share, downward pressure on dispensing margins (especially mail generics), and upward pressure on customer service levels and associated costs
  • Whichever of the big three US drug wholesalers that don’t get AMZN’s business. If AMZN ‘banners’ select independent pharmacies, this likely brings these select (presumably high volume) pharmacies into the same distribution network (i.e. to the same wholesaler) AMZN chooses, and leaves the less desirable independents to the remaining wholesalers
  • Physician practice management (PPM) software / systems providers (e.g. MDRX, ATHN) if AMZN moves into this space

 

 

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  1. It’s easy to see why ESRX and CVS/Caremark don’t want AMZN in mail order fulfillment (or even in pharmacy at all). These PBMs’ monopoly over mail fulfillment for their covered lives allows them to capture outsized generic and specialty-brand dispensing margins, making mail fulfillment a major contributor to overall profits. For HMOs who are managing prescription benefits within the context of the broader medical benefit, sub-contracting the pharmacy benefit (including mail fulfillment) to a traditional PBM means allowing the PBM to capture the mail dispensing margins, which finds its way back into the HMO’s overall premiums. These same HMOs could instead choose to set-up pharmacy formulary management and claims adjudication internally, and outsource mail fulfillment to AMZN. Customer satisfaction would rise, and the HMOs could control either all, some, or none of the mail dispensing margins (in this case the spread between what the plan sponsor is charged and what AMZN is paid)
  2. UNH/OptumRx would of course maintain control of the formulary, and could still capture a share of mail dispensing margins
  3. Pharmacy Benefit Management Institute (PBMI) “2017 Trends In Specialty Drug Benefits”, here: https://www.pbmi.com/ItemDetail?iProductCode=SPECIALTY_2017&Category=SPECIALTY
  4. Drug Channels Institute, “The 2017 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers”
  5. E.g. PillPack, Pharma Compliance Pack, Ecoslide-Rx
  6. E.g. Mango Health
  7. E.g. MedMinder, Adhere Tech, TowerView, Catalia Health, Nomi, TimerCap’s iCap, Clever Cap, Dose Cue, and others for pills; Propeller Health and Cohero Health for inhalers; KaliCare for eyedrops; Intuity Ject for injections
  8. E.g. Proteus Digital Health

©2017, SSR, LLC, 225 High Ridge Rd, 2nd Floor, Stamford, CT 06905. All rights reserved. The information contained in this report has been obtained from sources believed to be reliable, and its accuracy and completeness is not guaranteed. No representation or warranty, express or implied, is made as to the fairness, accuracy, completeness or correctness of the information and opinions contained herein. The views and other information provided are subject to change without notice. This report is issued without regard to the specific investment objectives, financial situation or particular needs of any specific recipient and is not construed as a solicitation or an offer to buy or sell any securities or related financial instruments. Past performance is not necessarily a guide to future results. In the past 12 months, through a wholly-owned subsidiary SSR Health LLC has provided paid advisory services to Pfizer Inc (PFE), Gilead Sciences (GILD), Bristol-Myers Squibb (BMY) and Sanofi (SNY) on both securities-related and non-securities-related topics. One or more of SSR Health’s analysts owns long positions in the following stocks: AERI, AGEN, AKAO, ALKS, ANAB, ARRY, BMY, DOVA, DPLO, ESALY, GILD, GWPH, INCY, IONS, KALA, KMPH, LJPC, NSTG, PFSCF, PGNX, PTLA, RARE, RHHBY, RIGL, THERF, TRVN, TSRO, VRTX


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