OPCH - NASDAQ

Good day, and thank you for standing by. Welcome to the Option Care Health Fourth Quarter 2025 Earnings Conference Call. [Operator Instructions] Please be advised that today's conference is being recorded. I would now like to hand the conference over to your first speaker today, Nicole Maggio, Senior Vice President of Finance. Please go ahead.

Good morning. Please note that today's discussion will include certain forward-looking statements that reflect our current assumptions and expectations, including those related to future financial performance and industry and market conditions. These forward-looking statements are subject to risks and uncertainties that could cause actual results to differ materially from our expectations. We encourage you to review the information in today's press release as well as in our Form 10-K filed with the SEC regarding the specific risks and uncertainties. We do not undertake any duty to update any forward-looking statements, except as required by law. During this call, we will use non-GAAP financial measures when talking about the company's performance and financial condition. You can find additional information on these non-GAAP measures in this morning's press release posted on the Investor Relations portion of our website. With that, I will turn the call over to John Rademacher, President and Chief Executive Officer.

Thanks, Nicole, and good morning, everyone. Thank you for joining us, and we're excited to share updates on our productive year and the 2025 results today. Before I do this, I want to take a moment to say thank you to the entire Option Care Health team for their consistent execution and commitment to our mission of transforming health care by improving outcomes, lowering total cost of care and delivering hope to our patients and their families. Before I get into the details on our business and financial performance, I'd like to reinforce our critical role across the health care industry. Option Care Health is uniquely positioned as the nation's largest independent provider of home and alternate site infusion therapy. We built a strategy on a national scale that starts with putting the patient at the center, provides high-quality care with cost advantages and fosters clinical innovation with local responsiveness. Last year, we served over 315,000 unique patients across a range of therapeutic categories, ranging from IV antibiotics to some of the most sophisticated rare and orphan products in the marketplace. In fact, last year, we completed over 2.5 million infusion events. Our 50-state licensure, expansive footprint and comprehensive nursing team help us deliver consistent clinical outcomes and same-day service for large health systems and national payers across the country. This includes helping payers shift care into lower-cost settings and reduce inpatient utilization where clinically appropriate. With the ongoing economic pressures the health care industry is facing, we are on the right side of the health care cost curve, partnering to provide high-quality care at an appropriate cost in a setting in which patients want to receive it. As we reported this morning, our results were in line with what we preannounced in January. Meenal will provide more detail, but I wanted to highlight the solid execution that drove our performance this past year. In 2025, the Option Care Health team continued to capitalize on industry dynamics and made significant progress in our efforts to create a sustainable growth enterprise. We opened new infusion suites and pharmacies, deployed innovative technology, deepened our referral base and expanded our formulary, while navigating a dynamic environment and shifting economics on certain therapies. As we reaffirmed this morning, our current views on 2026 are also in line with the guidance that we communicated in January. The team continues to execute at a high level every single day and the strength of our platform, our clinicians, our local market operations and the consistency of clinical outcomes across our national infrastructure continue to differentiate us and provide value to our stakeholders. Our partnership with payers continues to deepen as we help them navigate affordability challenges and find opportunities to rightsize care. We understand the pressure our payer partners are facing with rising health care costs as well as rate pressure for those with Medicare Advantage exposure. We see strong alignment between our capabilities and the outcome the payers are trying to achieve, and we expect that momentum to continue. We have active site of care programs with the largest national payers. And this year, we added 5 new programs with regional health plans and 2 additional with nontraditional payers. These programs are seeing traction, and we expect that number will continue to grow in 2026 and beyond. We remain committed to leveraging our platform to help manage the total cost of care, while producing quality outcomes through clinical oversight and helping to ensure adherence to medication care plans. On the formulary front, we see a strong pipeline of infused and injectable drugs to treat clinically complex patients, and we're encouraged by the engagement with pharma manufacturers and innovators, who are seeking partners with our capabilities. Our comprehensive clinical competencies, including one of the nation's largest network of infusion nurses as well as broad market access, national scale and local pharmacy resources positions us as a partner of choice to help new-to-market products reach their targeted patient cohorts. And our pharma partnerships also continue to expand, including earlier involvement through clinical trial support and enhanced service and data insight programs. We continue to invest in and strengthen our programs to create specialized service offerings, clinical effectiveness reporting and operational discipline to scale and configure programs with efficiency capture. Today, we are privileged to operate over 20 enhanced programs in service to pharma manufacturers, and we are excited about the pipeline of new programs we expect to launch in 2026 and beyond. Our referral source relationships remain strong as we have proven to be a reliable partner across health systems and specialty prescribers. Our consistent and disciplined approach helps us capture additional demand through increased reach and frequency with these referral sources. With the specialty prescriber base, we have aligned our commercial resources to improve focus on key call points. We see attractive growth vectors in neurology, autoimmune, dermatology, oncology and rare diseases, and we expect these therapeutic areas to play a larger role over time. The breadth of our portfolio continues to expand as additional therapies and indications are added, and we are excited about the opportunities ahead. We also continue to invest in growth across our platform throughout 2025. We added talent across commercial sales, operation and our clinical teams. We strengthened our technology stack to drive efficiency and scale. We continue to deploy artificial intelligence and automate key patient administration functions, including invoice processing and cash posting. Today, approximately 40% of our claims are processed without human intervention. We believe these initiatives will help us to grow without significant incremental labor within these functions, while improving the quality and productivity of our team members. Our ambulatory infusion clinic investments continue to progress well with over 25 centers offering advanced practitioner capabilities. These additional investments complement our home-based and alternate site model, expand patient choice and can support higher acuity therapies in cost-effective settings. To provide some context, on a pro forma basis for Intramed Plus, which we acquired in 2025, our infusion clinic visits grew over 25% in the fourth quarter over prior year. And we've seen continued momentum in both the Intramed Plus sites in South Carolina as well as within our other infusion clinic locations. We expect to further leverage our model as we navigate regulatory compliance and identify strategic locations for new clinics. Additionally, over 34% of our nursing visits this quarter occurred in one of our infusion suites or clinics, and we expect to continue to leverage the infrastructure we've built, which contributes to the results in both clinical capacity and efficiency. And with that, I will turn over to Meenal for a closer look at the financial results. Meenal?

Thanks, John, and good morning, everyone. As John noted, 2025 was a strong year for the organization, and our results reflect both the resilience of the business and the strength of our team. For the full year 2025, net revenue was $5.6 billion, up 13% over prior year, driven by balanced growth across acute and chronic therapies. Our teams continue to capitalize on evolving industry dynamics to capture volumes from both health systems and specialty prescribers. Acute revenue grew in the mid-teens, while chronic therapies grew in the low double digits. As discussed in our third quarter call, we began to see Stelara biosimilar adoption, which carries a lower reference price and reimbursement. For the full year 2025, we absorbed a company revenue headwind of 160 basis points from patient transitions to Stelara biosimilars impacting our chronic portfolio. Gross profit dollars grew 7.4% and our SG&A percent of sales declined 50 basis points versus last year to 12.1% as we continue to see the positive impact of our efficiency initiatives and leverage. Adjusted EBITDA of $471 million increased 6% over prior year, and our EBITDA margin was 8.3%. Adjusted diluted EPS was $1.72, growing 9% and reflecting the strength of our operating performance and the impact of repurchasing our shares over the course of the year. We generated $258 million in cash flow from operations for the full year 2025 and finished the year at a net debt to leverage ratio of 2.0x. As we shared in early January, we expected to finish below our prior guidance of $320 million. Consistent with prior years, we executed on some opportunities for strategic inventory buys, where we could achieve some favorable economics, including some opportunities that arose later in the fourth quarter. Additionally, we ramped up our working capital for certain limited distribution therapies more than we had estimated as clinical and operational investment is essential to support long-term growth. And overall, as we grew sales 13% this year, we naturally have some higher working capital carry to support the growth of our business. We are setting our 2026 operating cash flow guidance to be greater than $340 million, reflecting a 30-plus percent growth in cash generation versus last year. We are already executing on initiatives to reduce our working capital with a focus on inventory as we believe a significant portion is timing related. We are also taking a fresh look at our processes and practices around working capital management to continue driving our strong cash conversion cycle. Consistent with prior years, our cash generation is seasonal with the first quarter historically being the low point and the majority of our cash being generated in the back half of the year. Turning to capital allocation. We executed on all fronts in 2025, and our priorities remain consistent. Our primary focus remains internal investment to support profitable growth, capacity and efficiency initiatives. In 2025, we added over 80 infusion chairs as we continue to build out our suite in clinic footprint, where we identified strategic geographic growth opportunities, but we remain focused on maximizing utilization within our current infrastructure. We also invested in adding key clinical and commercial resources to the team. On our second priority, M&A, we remain active on identifying complementary tuck-ins and adjacencies. We acquired Intramed Plus earlier in the year, and the business and financial performance beat our initial expectations. We will continue to exercise discipline as we evaluate potential acquisitions, ensuring they are both strategic and financially attractive. And finally, we will periodically buy back our shares. We repurchased over $300 million of our shares during 2025. And as we announced in early January, the Board expanded our share repurchase program authorization by $500 million. As we look forward to 2026, we are reaffirming the guidance we announced in January. We expect full year 2026 revenue of $5.8 billion to $6 billion, which reflects a 4% growth at the midpoint and a 400 basis point revenue growth headwind driven by Stelara IRA and Stelara biosimilars conversion. We are guiding to adjusted EBITDA of $480 million to $505 million. This includes a $25 million to $35 million gross profit headwind related to Stelara and Stelara biosimilars conversion with the financial impact expected to be realized evenly over the year. We expect adjusted diluted EPS of $1.82 to $1.92, and as I noted earlier, expect to generate at least $340 million in operating cash flow. On some modeling items for the full year 2026, we're forecasting net interest expense to be in the range of $50 million to $55 million. We are estimating a full year tax rate in the range of 26% to 28%, and we are assuming a share count of 159 million shares for the first quarter. We are confident in the guidance we are putting forth and look forward to continuing our track record of execution. And with that, I'll turn it over to the operator to open up for questions. Operator?

[Operator Instructions] Our first question comes from David MacDonald of Truist.

Just a couple of quick questions. John, can you talk in a little bit more detail? I mean, it's hard to kind of get through a day without hearing about affordability. You talked a little bit in your prepared remarks about the payers. But can you also talk about not only just what you're seeing in terms of the payers? It sounds like those conversations are certainly incrementally ramping up. Let me know, if that's accurate. And then secondly, just what you're seeing in terms of conversations with potential hospital systems, just given some of the pressures that they're seeing and chatter around things potentially down the road in terms of maybe like site neutrality. Just any additional color there would be helpful.

Yes, absolutely. Dave -- so on the affordability, as I said in the prepared remarks, we're working closely with the payer community around helping to enable their focus around total cost of care and reducing that as it moves forward. We have in place, as we called out, site of care initiatives that help to identify opportunities to transition patients on to service with us and help to reduce that total cost of care, whether it's in the home, whether it's in one of our infusion suites or in one of our infusion clinics. So we've had programs in place. I would say the pace of those conversations has increased as the payers have been focusing around really their MLRs and looking for opportunities to maintain quality, but do it at a lower cost. And we're encouraged by those conversations and the opportunities that we believe that brings to us as well as to the patients that we have the privilege to serve. On the hospital system front, I'd say similar. There have certainly been strong relationships across the country with key hospital systems, focusing on helping to transition patients safely and effectively on to care with us, especially when they have a capitated DRG type of payment plan, they are always looking for the ways to help to transition those patients safely out of their facilities. We embed RNs into those hospital systems to help with that transition of care. We believe that, that's going to continue to be a strong point given the national scale we have, but that local responsiveness that we talk about. And that is the balance of the portfolio. We talk a lot about the acute and chronic portfolio that we have. That ability to serve the breadth of products as well as the breadth of patient population just positions us well to support the hospitals and health systems, whether it's an acute discharge for a patient on an IV antibiotic, whether it's supporting a 340B program on some of the specialty drugs, we have a wide range of programs that we work with the hospitals and health systems to enable them to be able to achieve the best outcomes.

Okay. And then just, John, a couple of other quick ones. Just in terms of Advanced practitioner, I just want to make sure I caught that right. Could you just run through, were those pro forma numbers across the entire advanced practitioner 25 locations. Was that just Intramed? Just -- I just want to make sure that I had that correctly, down correct. And then one other quick question. You talked about driving increased utilization of your existing footprint. Can you give us a sense, is it fair to assume that as some of these have matured, that roughly 20% increase that you've seen in nursing efficiency goes higher as these things mature and you further drive utilization within those centers?

Yes. So starting with the prepared remarks, the 25% increase was the Intramed sites as we took that over on a year-over-year basis just in the comparable, continue to make investments into that marketplace as we went through the integration of that asset as being part of the Option Care Health family. So really pleased about that. The rest of the sites are seeing the momentum. We didn't necessarily scale or call out the exact growth on that, Dave, but I just wanted to put it into perspective on the Intramed sites. On the overall efficiencies that we expect, yes, we continue to see growth in our patient census. I mean, as I called out in the prepared remarks, we served over 315,000 unique patients last year. That is an all-time high for this organization. It just shows the strength of the platform and our ability to reach into that. Continue to utilize the footprint, especially in the infusion suites and the infusion clinic, just allows us to drive both capacity and efficiency of the nursing network and continue to drive that forward. So we had called out before about a 20% improvement that we see in the nursing efficiencies over time. And that's part of that equation of where we're seeing the use of those sites to really help us drive the operating efficiency and leverage, but also to increase the capacity of our nursing community.

Our next question comes from Matt Larew of William Blair.

This is Jacob on for Matt. I just want to touch on the outlook to start. I appreciate you first guided about a month ago and today reiterated that guide. But just wondering, if you see anything that has made you maybe more cautious on the outlook for the year, whether that be updated numbers, expectations for Stelara. I know you reiterated the guide you had previously given for that. But just what kind of maybe early trends in the first quarter have showed you, maybe any ramping drugs or drug classes or anything from the recent IRA announcements as well as any upcoming biosimilar launches you'd highlight that could potentially affect numbers to the both ends of the guidance range this year?

Sure. Jacob, so I'll answer your question. I'll give you the short answer, which is no. We didn't change anything related to our guidance that we provided in January. We, of course, are keeping track of the landscape and the number of puts and takes that are going on, a lot of noise in the news these days. But from where we sit in the plan that we've put together, we still feel very good about the guidance that we've set forward, both from a sales growth perspective as well as profitability. And then we also added in the cash flow guide in that. So we feel -- we haven't really seen anything that would lead us to changing anything in the guide right now. I don't know, John, if you want to speak to trends?

Yes. I think the overall trend is in alignment with our expectations. We had done a lot of planning heading into the year. And certainly, when we were formulating what was going to be that pre-release guide that we put forward. I think what we're seeing at this point in time is that things are trending in alignment with kind of our expectations. As you know, the first quarter is a very busy time with benefit verification and reauthorization and prior authorization for new patients coming on to service. And so there's always a bolus of activity that kind of comes at the beginning of the year. It really takes the quarter to fully shake a lot of that out. But at this point in time, we're very confident in the '26 guide and continue to believe that everything is patterning in line with our expectations. To your broader question, and as Meenal said, there is a lot of noise in the marketplace at this point in time. We're trying to separate the signal from the noise. And again, we don't see anything in '26 that really is changing our perspective around where we see the growth and where we see the opportunities that lie ahead. So I think the team is staying close to any of those developments. But at this point in time, we feel very good with the guidance that we have reaffirmed this morning.

Got it. And I want to go back just quickly on the advanced practitioner model. I think in last quarter, you mentioned 24 of your 175 total facilities were equipped this model. I think I heard over 25 this quarter. So just wondering what your target pace for convert earning and opening new sites in 2026 and beyond this. And maybe as a follow-up to that, as you scale both the infusion and these advanced practitional models, what are kind of the key limiting factors for increasing the pace of the new site openings? And maybe what does the plan to invest in those capabilities look like in the next couple of years versus what that looked like in the last couple?

Yes. So as we've expressed before, I mean, we have a pretty big installed base of our infusion suite, and there's kind of a collective approach that we're taking on our infusion clinic build-out. Some of them are new sites that are greenfield that we are building, when we find strategic geographies in which we want to have that capability. And others are the conversion of our existing sites to transition them over and get the licensure, and there's a modest amount of refurb that needs to happen in order to make them an infusion clinic. So we're kind of going about it in both ways as we see the market opportunities and driving that forward. As we called out and as you heard, we have continued to grow that in the fourth quarter, and we expect that we're going to continue that conversion and growth into 2026. I don't know that I'm willing to put a target out there at this point in time. It moves in some way an interesting pace. I think as we've explained before, a lot of it has to do with corporate practice of medicine at a state level and the ability to get credentialing with the payers through that process. And so we're actively moving forward with that. One of the big aspects of where we really can drive the utilization is the investments that we also called out in investing in our commercial resources, having the sales team that is making the call, certainly investing in the clinical resources that are necessary to be able to oversee those clinics and operate within that environment. And then this balance of the operating model where a patient is best served under the practice of pharmacy or where a patient is better served under the advanced practitioner model and balancing those out. So we continue to make investments across all those dimensions. We believe this is additive to our overarching strategy of being a partner of choice and having a choice for patients to select the best site for their care. And so we're going to continue down the pace, and I would expect that you're going to continue to hear us talk about the growth that we're seeing in the existing installed base as well as continue to make additional investments to expand our capabilities and expand the network of advanced practitioner clinics.

Our next question comes from Pito Chickering of Deutsche Bank.

I guess the first one here, just a quick housekeeping. Can you quantify the Stelara impact you guys saw in the fourth quarter? I just want to be able to model what gross profit growth year-over-year was excluding Stelara. Was that in line with your sort of $20 million to $22 million of EBITDA impact in the fourth quarter?

Yes. The short answer is yes. In the end, for Stelara and the headwind that we talked about, which was close to the $70 million or so, it patterned out exactly as we thought. And so if you assume about $20 million of an impact in the fourth quarter, maybe a little more, that's over 100 basis point impact to gross profit.

Okay. Perfect. And then looking at your split between acute and chronic growth for '26. Just sort of curious how you view the acute growth this year? Obviously, it's been a couple of big years post -- or big year post competitors exiting. I guess how do you view the revenue growth of acute in '26? And then also same question, how do you view the chronic growth in '26? And then the follow-up there from a margin perspective, is there any reason why the margins in '26, excluding Stelara, would change versus the last couple of years within those 2 segments?

Yes. So we expect to continue to see strength in our acute offering. As you called out, Pito, the marketplace continues to be dynamic there, but we believe we're well positioned. And the infrastructure that we have and the capability set really plays well to capture that market demand. I think we have characterized that the industry of those types of product is a low single digit. Our expectations is probably a mid-single digit on that so that we will continue to capture the market demand as it moves forward. Again, that's a step down from the prior year, where we had the competitive closures, but it still is a strong result on that. I would say the profit contribution on the acute would be consistent with what we would expect and what we've seen in prior years. No major changes from that perspective. On the chronic, again, given some of the headwinds of the biosim and the Stelara, we still expect that to be in the high single-digit, low double-digit growth on the chronic standpoint. Again, as you had called out, certainly, we have the headwind of the biosimilar and Stelara impact on a year-over-year basis. But the rest of the portfolio, I would say, is in alignment with kind of what the historical expectations or the historical performance has been from that. We're going to continue to have to fight through a little bit of a mix challenge in the sense we're going to be growing our chronic faster than the acute, and that's going to put some pressure on the gross margin as a percentage aspect. But again, we feel good about the strength and the breadth of the portfolio. And as we called out, we're punching above our weight class in some of that aspect where you're working through the headwinds of Stelara and putting that behind us in 2026.

Our next question comes from Brian Tanquilut of Jefferies.

John, maybe to follow-up on your points to Pito. As I listened to your prepared remarks and heard all the things you were talking about in terms of the drivers of the business going forward, your AI benefits and the fact that your business probably can't be AI. So when we think through all that and the fact that Stelara is behind us now, is it right to think that we should revert back to sort of a double-digit EBITDA trajectory once we get to 2027?

Yes. I mean, look, Brian, we don't give '27 guidance on the day that we gave out '26 as you expect. But the fundamentals of the business, I guess, part of the prepared remarks were around the fundamentals of the business being strong. We believe we're on the right side of the cost quality equation. We believe that we continue to partner with payers and pharma and really have a unique platform for our stakeholders to help achieve their goals as we're achieving our goals. There is -- there will continue to be opportunities as we see the portfolio of products that are entering the marketplace as well as the ability to use our clinical resources to the fullest across that. So I think things are setting up really well for us to continue to drive the business forward. I think we're extremely well positioned to capture that market demand and deepen the partnerships with those key stakeholders. And I think as we move through the year and continue to make progress against the objectives that we've outlined, I am confident in the strength of the position that we hold and really confident in the opportunities that we have to continue to capture market demand and really drive around those new vectors of growth that I outlined.

Yes, it's Meenal. Just the other thing I'll add when we put forward our '26 guide, we talked about -- there's a couple of headwinds in there, 400 basis points related to hopefully, the last couple of quarters, we'll talk about Stelara. So 400 basis points headwind on the revenue side. But then with the $25 million to $35 million EBITDA impact we talked about, if you take that out of the growth rate that the guidance implies, that puts us at a double-digit EBITDA. So that's what we're striving for, echoing everything John said about a lot of the initiatives, a lot of the work that we're doing. And we're just really focused on 2026 as a year of execution on a number of different initiatives and investments that we've made.

That's very helpful, Meenal. Maybe my follow-up, as I think about your guidance for the year, what assumptions have you made in terms of biosimilar shifting within the Stelara portfolio or even through other therapies like Tremfya? Or question asked differently maybe, is there upside opportunity as those things occur over the course of the year?

Yes. I mean we entered the year with assumptions around the portfolio and the census of chronic inflammatory disease kind of the broader category, Brian, inclusive of that Stelara, knowing that there were going to be shifts to biosimilars, there were going to be shifts to other products in the portfolio. And some of it was going to be led by the PBMs and payers around their formulary management and the way that they were aligning around those opportunities. I think as I said in a previous question that was asked, I think, it's patterning the way we expected it to or at least close to that, which gave us confidence to reaffirm the guidance today. It's -- those shifts, the first quarter is a really important quarter just because of all the prior authorization and reset that happens through that process. I think as we get through the end of Q1, we'll have a better sense around how everything is going to shake out on that. But at this point in time, it's in alignment with kind of our expectations. There's really nothing else that is on the horizon in 2026 that we think has material impact on the portfolio, either with new product entrants or biosimilar conversions other than the Stelara as we have called out.

Our next question comes from Lisa Gill of JPMorgan.

John, I wanted to go back to your comments around the expanded formulary. You talked about a strong pipeline in infused and injectable products. Can you maybe just talk about any specific opportunities that you see? I know in the past, you've called out, for example, rare and orphan products and large dollar amounts, but smaller gross margin percentages. Anything that we should keep our eye on as we think about '26? And then just kind of dovetailing into that, when I think about the strategic inventory buys that you talked about, should we think about that also as more of a first quarter impact? Or is that also going to be spread throughout the year? How do I think about the cadence of some of this?

Yes. So I'll start, Lisa. Yes, thanks for the question. I think when you look at the formulary and kind of the opportunities that we see in the pipeline, I would guide us a little bit more towards some of the rare products. The platform that we have, the clinical capabilities -- we had -- and we had announced earlier that we have 2 additional platforms that are going to be starting in 2026. A little bit hard on some of those products to know what the uptake is going to be and with PDUFA dates and things of that nature as to when the actual launch will happen. But we have 2 programs that will come online in 2026 in addition to the portfolio that we have. We think the platform itself is really -- has strength in the pharmacy infrastructure, the infusion suite infrastructure and the clinic infrastructure as well as the clinical competencies that we have to continue to partner deeply with pharma on that. So I think you'll hear more about that as things progress, and those are areas of focus. There are additional products that are coming in, in the chronic space that, again, we feel encouraged about either expanded indications and/or an opportunity for entrance of new products into the portfolio. So look, I'm not going to call out single products for various reasons. But the strength of the team that we have in place that works with pharma manufacturers to identify those opportunities to make certain that we're on formulary or it's a part of our formulary and we're able to bring it in. And in some instances, either through a limited distribution or exclusive arrangement, we're always looking for how to leverage our infrastructure to the fullest and be a really strong partner to pharma as they're looking for channel partners to be able to reach their patient cohorts.

Yes. And Lisa, I'll answer the cash flow question for you. In general, we would expect -- and maybe I'll take a step back. I talked about in the prepared remarks that we had -- as we've typically done, we made some strategic inventory purchases. Some -- there were some decisions late in the fourth quarter when we did that. As typical during the year, we'd expect it to get used up. Whether that's exactly evenly through the quarters, it's a little chunkier with cash flow, but I would expect it would go through the year. And just a reminder, I would also say that as we think about cash flow seasonality, we've historically seen, where Q1 tends to be the lightest cash flow quarter tends to be much stronger in the back half. So it's hard to see where the inventory patterns will match in there, but we will comment on it, and you'll see tracking coming through with just inventory balances shrinking throughout the year.

Just a follow-on to your capital allocation strategy. I've heard both you and John talk about Intramed being very successful. How should I think about '26? Do you see incremental opportunities for another Intramed or other types of tuck-in acquisitions in '26 versus share repurchase?

Yes. I mean I'll start with this. As I think about our M&A strategy, we're absolutely -- that's a big focus. We've talked about organic investment followed by M&A. We have added additional resources to really focus on this area. And so we're continuing to evaluate a number of different opportunities that are out there. I just remind folks, right, you see what's above the water line. You don't see all the swimming going on underneath the water line, but there's definitely a lot of activity and M&A remains something that we go after. Intramed-like assets have been terrific for us as we've gone through in the past. So that's definitely a focus area for us. John?

Yes. And I would just echo that. I think that we're managing a pipeline of opportunities at this point in time. And as Meenal said, we continue to invest in that team and the capabilities to assess and then do that. The only thing I will continue to remind everyone is it's got to be both strategic and financially accretive for us as we're looking forward. That's the discipline that we've demonstrated historically, and it's one that we'll continue to maintain as we look ahead.

Our next question comes from A.J. Rice of UBS.

Just to put a finer point on the seasonality, I'm interested on the income statement. You got the $25 million to $35 million gross profit headwind. I think the assumption with the way things played out last year was because you had forward buying that mitigated the impact of Stelara in the first quarter last year, the comp will be particularly tough in the first quarter this year and then get more normalized for the rest of the year. It sounds like you've got forward buying you're doing again this year. So should we think of that $25 million to $35 million headwind as being evenly distributed? Or is first quarter still going to be a tougher comp than the rest of the year with respect to that?

Yes. So let me answer both questions, A.J. So one, as it relates to 2026, and I talked about and this hasn't changed that the $25 million to $35 million headwind, we would expect to pattern out fairly evenly throughout the year. So there isn't that first quarter phenomenon that occurred last year. Having said that, when you look at the year-over-year comp, because of what happened in 2025, there is a bit of a year-over-year comp issue in Q1 where it was more favorable in Q1 last year, but not necessarily this year. So hopefully that answers what you were trying to get at.

Okay. No, I got it. I got it. And then I know John mentioned the application of AI and claims processing and things you're doing there. We're hearing providers talk about AI applications in various ways. I was curious when you go beyond that, is there any other applications that you're looking at for AI, whether clinician utilization staffing, other things that would be worth highlighting?

Yes, A.J. I would highlight that we're doing work with some agentic aspects for, as you would expect, call center capabilities and the ability to help better support customer service. We're doing work around workforce optimization and making certain that we have the right resources in the right places. As part of the overarching comments that Meenal made around strengthening some of the things on working capital, we're looking at tools to help better manage inventory and things of that nature. So I'd say it's broader than just revenue cycle manage at this point in time. The use cases that we have are expanding. And these are all, I guess, tools that augment our team. They help our team work more efficiently, more effectively and in instances, reinforce quality through that process. We have not done anything at this point in time to really put it in front of the clinician. We believe that the models are still a little bit immature in order to do that. We may look for opportunities to help support our clinicians in note capture and other aspects. But at this point in time, we have not done anything to put it in the pathway of the clinical protocol.

Yes. And the other thing that I'd add, A.J., is just as AI becomes there, I say, more mainstream, et cetera, there's a lot more, as John referred to, there's certain things that are now off the shelf that we're looking at or even when we're working with other vendors and partners where they're utilizing AI and other tools to help us -- help what they're doing for us on efficiencies. Those are other areas that are going on as well. So it's much broader, as John had said, it's much broader than just looking at the revenue cycle management area.

Our next question comes from Joanna Gajuk of Bank of America.

Just a couple of follow-ups. In the prepared remarks, when you talk about payers, you had mentioned 5 new programs with regional and 2 with nontraditional payers. Can you give us a little more color, especially the nontraditional payers, what exactly are you referring to?

Yes, Joanna, it's John. So there are conveners in the marketplace that are either trying to create a better solution for payers themselves and/or direct to employers. So those are the nontraditional partners that we're working with that allow us to expand our reach into the marketplace, but also be a partner across the payer community at the national, regional and the convener level.

So when you work with these conveners and I guess sounds like direct-to-employer relationships, I guess, are these rates comparable to what you negotiated with commercial base or maybe that's better because it sounds like these parties look for solutions and maybe they're willing to pay a little bit better rates. I don't know. Can you give us a little bit of flavor on that?

Yes. I would say they're comparable within the way that the reimbursement, although some of the conveners and some of the, I guess, the more innovative organizations are continuing to take a look at capitated programs and looking for ways to help to manage the patient base in a more comprehensive way. So they're trying to innovate around those aspects, and we're working with them around thinking about new models as well as existing models that they're operating with. So -- but I would say we're seeing that it's -- they're comparable in the reimbursement. And in some ways, they just help us continue to innovate and make certain that we're thinking about the total cost for care in a broader sense.

Okay. That makes sense. If I may, another follow-up. So you were talking on multiple occasions, I guess, around cash flows, but also in terms of the products and portfolio around limited distribution drugs. Just can you give us a sense of, I guess, how many you have and how many, I guess, you added in '25, how many you're adding in '26? And I guess, are you seeing any increased competition for these limited distribution drugs in the marketplace right now or less competition for that matter, but just any additional, I guess, commentary will be helpful.

Yes, Joanna. So we have over 20 platforms that we operate today that are either rare or limited distribution drugs that are part of our portfolio. We had called out in previous calls that we were adding 2 additional programs in '26 as of this point. These are normally -- especially on the rare side, they tend to be higher-priced products. There is some working capital build that comes with that as we're putting inventory into our infrastructure and helping support the commercialization of those products. So that's part of the working capital that Meenal had called out and some of the things that we use cash in '25 and '26 as we move forward. But we feel really good about the platform. When you think about the breadth on a national scale, the access points that we have, the relationships we have with the payers and then the clinical competencies of this enterprise, we continue to believe we are well positioned to compete for those. There are competitors in the space. It's -- as you would expect, in all of health care, it's highly competitive, but we believe that we're creating a very unique platform and have an opportunity to win our fair share of those type of programs as we move forward.

Our next question comes from Charles Rhyee of TD Cowen.

Maybe, John and Meenal, a month back when you guys sort of outlined sort of the initial guidance for the year, I think there was sort of an assumption that you'd be looking at sort of -- it was early. You didn't know what your Stelara sense would look like. And so the assumptions you're putting out there, I think you were trying to -- if I understood it correctly, was taking kind of a conservative assumption on that. We fast forward here about 1.5 months, you kind of reaffirmed the guide. Anything about that in terms of what you have done maybe thought of what your census looked like versus what you're actually seeing now? Has anything changed or gotten better or worse? And then, John, I think you mentioned 340B in one of the -- in response to one of the questions earlier. Can you kind of talk about how you support 340B? And what is your -- maybe any kind of exposure you have to the program? I know there's some concerns around -- obviously, there's some regulatory risks that pop up now and then around that. Just curious how you are -- how do you work within the 340B program with your acute care partners?

Yes. Charles, why don't I -- I'll take the first part of your question on Stelara. So as we talked a little bit earlier, there's a lot of activity that always goes on in the first quarter with New Year benefit verification and formulary changes and just with a lot of the broader noise across the industry right now, it's been probably a lot more than that. Despite all that, when we look through all the activities and where we are today, we're not really seeing any substantial differences versus what we had assumed a month ago, when we thought about, I'd call it, Stelara and all the different potential formulary options that could be out there for patients. So if there was anything that would have caused us to rethink our guide, we would have incorporated here. But as I think John mentioned earlier, there really isn't anything that's substantially different. And it's still going to take us another month or so through the end of the quarter really to get through all of this new year activity as is pretty typical, but a little more enhanced this year just with other industry noise going on.

Yes. And then, Charles, on the 340B side, again, this is an additive program that we operate in support of our health system and hospital partners. Our model is one in which we either qualify as a pharmacy under the 340B criteria, and we just pass the savings on to the hospital. So like we're -- we certainly dispense the product and are able to get the economics that are normal with that. But any of the 340B savings is just a transfer of those savings back to the hospital. So we help to facilitate that and drive that forward. I wouldn't say it's a meaningful part of our overall economics in our overall program, but we like to support the hospital and health systems. We like to be able to bring them the benefits and the savings that could be generated when they're a disproportionate hospital. And we work with the clearing houses and across that in order to facilitate the savings to be passed on to the hospital.

So just to be clear, so that means if there were to be any changes in 340B pricing, that would have no impact for you guys because that's sort of a pass-through on your end?

Correct. Yes. I mean that's the way we've approached it.

All right. That's really helpful. And maybe just one quick follow-up on OpEx growth for this year, how should we think about -- I think last year, we saw some elevated expense related to the Intramed acquisition and investments in the business. Can you give us a sense, Meenal, sort of what we should be thinking about in terms of OpEx growth, anything kind of onetime or any things that are coming out?

Yes. When I take a step back and maybe I'll answer it in a '25 context and looking forward, when I think about 2025, our SG&A on print does look like it's up a little bit versus gross profit, and that's the lever that we're taking a look at. When you start to strip out, as you point out, Intramed and there's some GAAP-only charges that are sitting in SG&A and you take some of that out, we're actually in line or a little bit down on SG&A growth versus gross profit growth. So that's -- I mean, that's where we expect to trend as we think about going forward. We still have, I'd say, in '26, maybe a little bit more on the investment side that we're doing. So you may see a pattern slightly higher than gross profit. But as we look forward, we look for something closer to a leveraged model versus gross profit.

Our next question comes from Erin Wright of Morgan Stanley.

I just have kind of one bigger picture, just higher-level question just on the competitive landscape and just thinking about some of the historical tailwinds with competitors exiting the market. I guess, can you talk a little bit about the runway left on that front? How much does that continue in terms of a tailwind for you? And are there other dynamics, I guess, to call out in terms of looking at the landscape and your ability to take advantage of some of those opportunities?

Erin, I think as we're looking ahead, we certainly don't see as big of a significant shift that we've seen over the last couple of years with 2 major competitors kind of resetting their network design and the product portfolio that they were serving. We still believe there's opportunities to take share in the market. We're well positioned. We like the infrastructure that we've built. We love the breadth of the network, but also understand health care is very local, and we have to win at the local level. So we're doing everything we can to be that reliable and consistent partner to be able to help with the transition of care for patients or be able to help them live their best life through the activities of our clinical teams in support of those care plans. So the market in general, I mean, if you take a look at some of the data, the market for infused products is over $100 billion. We're $6 billion of that. So we think there's still continued runway for us to be that partner of choice and to compete vigorously, but know that this is a hustle business, and you got to do it every single day.

Our last question comes from Raj Kumar of Stephens.

Maybe just kind of thinking about the kind of investment thesis around kind of just the internal spend and kind of the opportunity set that you've talked about around oncology and neuro. As we think about the kind of investment spend in 2026 and the capturing us that opportunity, is that more so that there needs to be internal capabilities that still need to be built out or potentially acquired to capture oncology in the home-based care setting? Or is it kind of more on the sites of care initiatives front in terms of just payer or hospital partner, acute partner education? And then maybe kind of on the AI initiative front and thinking about what was realized on 2025, any way to frame the benefit in terms of, if it drove increased throughput or any cost efficiencies, that would be kind of helpful.

Yes. So let me start with maybe the AI first. So as we had called out, I think the measurable response is when you're able to do 40% of your claim processing without actually having human intervention, you can see the benefits that are driven on that. Again, that allows our team to focus on the higher complexity claims, those that need additional support in order for us to get fair reimbursement for the services that we rendered. So our focus has been around there, but we're seeing those tangible results. And I think you see it in both cost of service as well as SG&A over time, knowing that you've got to invest a little bit ahead of benefit on some of those to be able to drive that forward. On the overall investments in our business, I think we remain a capital-light enterprise. I mean, I think for the next year, we'll be in that $40 million to $50 million range of CapEx as we're looking at the range of opportunities to deploy capital to grow our business. We'll go about your call-out on oncology or others. That's a two-pronged approach. There is investments that are required in the commercial team and being able to reach into the call points. There are some capabilities around the clinical protocols and the clinical programs that need to be developed in support of that. There's certainly the utilization of our infusion suites and our infusion clinics as part of that comprehensive view as well as the ability to transition patients to the home. So I'd say it's across all of those dimensions. And as we're looking at where we deploy our capital and the return we expect on those, we have a disciplined approach that Meenal and team lead to help to us to really assess the value that can be created there. But we think there's a significant amount of opportunities for us to look at those new vectors and continue to invest in the people, process, technology and facilities that will be required for us to win.

And the last comment I'll add on that is with all the investments John is talking about, we definitely have made investments in 2025, and you can see that. So you're going to see an annualization of that into '26. And plus like on the commercial resources side, that's an area that we're really leaning into and there's some additional investments we're making. That's part of the comments that I was addressing previously on still a little bit more SG&A growth that's going in ahead of the growth and the benefits we expect to achieve.

I am showing no further questions at this time. I would now like to turn it back to the President and CEO, John Rademacher for closing remarks.

Yes. Thanks, Amber. In closing, I want to highlight the resilience of our platform and strength of our team and the underlying fundamentals of the business. We're well positioned to take advantage of the opportunities ahead of us, and I've never been more confident in the team's ability to capture demand for the extraordinary care and hope we deliver to patients and their loved ones. Thank you, and take care.