The Top 15 Specialty Pharmacies of 2024: How PBMs, Health Systems, and Independents Are Shaping the Market

Drug Channels Institute’s (DCI’s) latest analysis reveals that PBM-affiliated specialty pharmacies continue to dominate the dispensing of specialty drugs.

DCI has identified nearly 1,900 dispensing locations with specialty pharmacy accreditation. Below, we share DCI’s latest analysis of the top 15 specialty pharmacies, including updated market shares and revenue estimates.

As in prior years, pharmacies linked to the three largest pharmacy benefit managers (PBMs) accounted for two-thirds of prescription revenues from pharmacy-dispensed specialty drugs. We also explore how these pharmacies contribute to PBMs’ profitability—and spotlight the growing influence of provider- and health system-owned dispensing channels.

Once again, “specialty” mostly means affiliated with a PBM.

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2024 MARKET TRENDS

This post is the fourth installment in a series based on insights from DCI’s new 2025 Economic Report on U.S. Pharmacies and Pharmacy Benefit Managers.

Here are the earlier articles in the series:

• The Top 15 U.S. Pharmacies of 2024: Market Shares and Revenues at the Biggest Chains, PBMs, and Specialty Pharmacies

• The Top Pharmacy Benefit Managers of 2024: Market Share and Key Industry Developments

• Mapping the Vertical Integration of Insurers, PBMs, Specialty Pharmacies, and Providers: DCI’s 2025 Update and Competitive Outlook

DCI’S DATA AND OBSERVATIONS ON SPECIALTY DISPENSING

In 2024, retail, mail, long-term care, and specialty pharmacies collectively dispensed an estimated $265 billion in specialty pharmaceuticals—an 8.0% increase over the revised 2023 figure. The chart below ranks the top pharmacies by estimated dispensing revenues from specialty pharmaceuticals. The figures include all dispensing formats of the respective businesses. We cover many of the individual companies listed below in the subsections of the report’s Section 3.3.

[Click to Enlarge]

Our observations on today’s marketplace:

• Dispensing of specialty drugs remains highly concentrated. In 2024, the three largest specialty pharmacies generated two-thirds of all prescription revenues from pharmacy-dispensed specialty drugs. These businesses are all owned by vertically integrated organizations that also operate PBMs.
  
  The concentration of specialty dispensing revenues results largely from strategies used by both payers and manufacturers to narrow specialty drug channels.

• The largest PBMs derive an increasing share of profits from specialty drugs. Specialty dispensing accounted for about one-third of PBMs’ total gross profits in 2024. (See Section 11.2.3. of our new report.)
  
  These profits come from revenue sources that may not be transparent to the PBMs’ plan sponsor clients, including:
  
  • Superior margins from acting as contract pharmacies in the 340B Drug Pricing Program (Section 11.5.5.)
  • Markups on nonbiological specialty drugs (Section 12.2.3.)
  • Service and data fees from manufacturers (Section 3.4.2.)
  • Revenue sharing with copay maximizer vendors (Exhibit 147)
  • Tailored definitions of specialty drugs (Exhibit 8)
  • Dispensing spreads from PBM-affiliated private label products (Section 5.2.5.)
  These mechanisms allow PBM-owned pharmacies to underprice non-affiliated specialty pharmacies while also benefiting from scale-based purchasing advantages.

• Hospitals and health systems operate 27% of accredited specialty pharmacies—up from 15% in 2017. In response to changes in manufacturers’ policies regarding external contract pharmacies, hospitals continue to expand in-house specialty pharmacy operations. They also benefit financially by directly participating in the 340B program. In addition, self-insured health systems increasingly steer prescriptions to their in-house pharmacies.
  
  The proliferation of oral and self-injectable specialty medications has also encouraged more physician office dispensing. Consequently, non-retail settings’ share of patient-administered, oral oncology products purchases has increased from 21% in 2017 to 32% in 2024.

• Specialty drugs’ share of total dispensing revenues has fallen. From 2013 to 2024, specialty drugs’ share of total pharmacy dispensing revenues rose from 24% to about 39%. Over the past two years, however, specialty drugs’ share of revenues has declined due to:
  
  • The launch of generic nonbiological specialty drugs
  • Slower growth in brand-name drugs’ list prices
  • Rising sales of nonspecialty GLP-1 anti-obesity medication
  • The adoption of biosimilars for widely-utilized biologics

• Independent specialty pharmacies face headwinds. While independent pharmacies represent the largest number of accredited locations, they command a shrinking share of overall revenues.
  
  Fewer startups are emerging, and many major independents have been acquired. M&A activity peaked in 2016 and has since slowed, though the remaining independent players are typically larger and well-capitalized. Independent and smaller specialty pharmacies have been the big winners in manufacturers’ exclusive dispensing networks.

The specialty pharmacy market remains a critical—and increasingly contested—component of the U.S. drug channel. As PBMs deepen their vertical integration and health systems expand their in-house capabilities, the competitive landscape will continue to shift.

NOTES FOR NERDS

• Most companies do not report prescription revenues from specialty drugs. DCI has therefore used various methods and primary sources to estimate the data. In some cases, the companies provided us with revenue figures. Certain data have been updated based upon new disclosures since the previous edition of our report.

• As noted in the exhibit’s footnotes, DCI has made various adjustments to account for the pro forma impact of mergers and acquisitions as well as certain client transitions among the largest PBMs. Pro forma revenues are computed based on the year in which an acquisition was completed. Year-over-year growth rates were also computed based on the prior year’s pro forma revenues.

• Revenues in the “All other retail, mail, long-term care, and specialty pharmacies” category come from the many pharmacies now competing to dispense these expensive therapies. As we discuss in the report’s Chapter 3, the specialty market’s growth continues to draw a diverse set of companies into the business of dispensing specialty drugs.

• The market size figure excludes estimated revenues from provider-administered specialty drugs billed under a patient’s medical benefit.