Q4 2025 The Oncology Institute Inc Earnings Call

March 12, 2026

Speaker #3: And finally , we strengthened our balance sheet during the year . We reduced debt on our convertible preferred note by 24 million and ended the year with 33.6 million in cash .

Speaker #3: After experiencing positive free cash flow in Q4 , giving us additional flexibility as we continue to grow the platform Operationally , we also made meaningful progress expanding our care model , our delegated capitation partnership with elements in Florida continued to ramp during the fourth quarter and remains on track to continue expansion across the state in 2026 , which would more than double the current partnership Today , we have approximately 70,000 lives under capitated arrangements .

Speaker #3: Within this partnership Given the economics of our delegated model , it's also worth highlighting that delegated members represented less than 5% of total capitated lives at the end of 2025 .

Speaker #3: But account for approximately a third of our run rate . Capitated revenue , reflecting the higher Pmpm structure associated with these arrangements and the high utilizing populations they service .

Speaker #3: In addition to elements , we also initiated capitation agreements with Humana and Careplus in Florida during the fourth quarter . Further expanding payer partnerships and representing approximately 22,000 additional lives in South Florida .

Speaker #3: Our Florida oncology Network platform also continued to grow with the number of participating providers increasing to approximately 207 physicians and advanced practice providers across our network , supporting what we refer to as our hybrid model of patient care , which allows us to treat our managed populations at a combination of T affiliated as well as independent clinics and our employed clinics .

Mark Hueppelsheuser: The press release announcing The Oncology Institute's results for Q4 2025 is available at the investor section of the company's website, TheOncologyInstitute.com. A replay of this call will also be available at the company's website after the conclusion of this call. Before we get started, I would like to remind you of the company's Safe Harbor language included within the company's press release for Q4 2025. Management may make forward-looking statements including guidance and underlying assumptions. Forward-looking statements are based on expectations that involve risks and uncertainties that could cause actual results to differ materially. For a further discussion of risks related to our business, see our filings with the SEC. This call will also discuss non-GAAP financial measures such as adjusted EBITDA and free cash flow.

Speaker #3: Under our fully delegated network umbrella, finally, from an organizational standpoint, we strengthened the leadership team substantially in 2025 with the additions of Jeff Langsam as Chief Clinical Officer and Kristen England as Chief Administrative Officer.

Mark Hueppelsheuser: Management may make forward-looking statements including guidance and underlying assumptions. Forward-looking statements are based on expectations that involve risks and uncertainties that could cause actual results to differ materially. For a further discussion of risks related to our business, see our filings with the SEC. This call will also discuss non-GAAP financial measures such as adjusted EBITDA and free cash flow.

Speaker #3: Both bring significant experience scaling healthcare organizations and will play an important role as we continue expanding our platform and executing on our growth strategy as we move into 2026 , our focus remains on continuing to scale and drive profitability in our value based care platform so that we can serve more patients and payers across the country with high quality oncology care .

Speaker #3: While improving access to therapeutics and reducing the financial burden of that care First , we expect continued strong growth in our delegated capitation model .

Mark Hueppelsheuser: Reconciliation of these non-GAAP measures to the most comparable GAAP measures are included in the earnings release furnished to the SEC, and available on our website. Joining me on the call today are our CEO, Dan Vernick, and our CFO, Rob Carter. Following our prepared remarks, we'll open up the call for your questions. With that, I'll turn the call over to Dan.

Speaker #3: Having guided in January to over 80% growth in capitated revenue for the year, Second, we are preparing to launch a proprietary new network portal in Q2, which will further strengthen engagement with both our affiliated and independent providers.

Speaker #3: The platform will improve visibility into utilization management pathways , support formulary adherence , and help drive continued improvement in our medical loss ratio Importantly , it will also help enable ancillary services engagement , such as part D dispensing adoption across our independent network providers , which remains a meaningful opportunity for incremental growth Finally , we strengthen our Board of Directors in Q1 with the additions of Mark Stolper and Kim Zoumakis .

Daniel Virnich: Thank you, Mark. Good afternoon, everyone, and thank you for joining our Q4 and full year 2025 earnings call. Before getting into the results, I wanna start by thanking our physicians, clinicians, and employees across the Oncology Institute. Their continued focus on delivering high quality oncology care in the community is what drives the progress we are seeing across the business. Most importantly, the Q4 marked an important milestone being our first profitable quarter as a public company from an adjusted EBITDA perspective. Based on the momentum that we have built, we are reaffirming our expectation to achieve full year positive adjusted EBITDA in 2026.

Daniel Virnich: Most importantly, the Q4 marked an important milestone being our first profitable quarter as a public company from an adjusted EBITDA perspective. Based on the momentum that we have built, we are reaffirming our expectation to achieve full year positive adjusted EBITDA in 2026.

Speaker #3: Mark bringing significant financial leadership and public markets experience . As a longtime CFO of Radnet , while Kim brings deep expertise in oncology and pharmacy services through her prior leadership roles as CEO of Vital One and 21st Century Oncology , respectively .

Speaker #3: We believe both will add valuable perspectives as we continue scaling the organization . In summary , 2025 was a foundational year for toy .

Daniel Virnich: The biggest driver of this progress continues to be the expansion of our capitated care model, particularly through our delegated arrangements, which enables us to manage the oncology benefit more comprehensively while aligning incentives with our payer partners across markets and delivering quality clinical outcomes to the patients that we serve. Stepping back, 2025 was a very productive year for TOI and one where we made progress across multiple areas of the organization. From a financial perspective, we delivered strong top-line growth with revenue increasing approximately 28% year-over-year and surpassing $500 million for the first time in our history. We continued expanding our capitated footprint, initiating 9 new capitated contracts during 2025 in California, Florida, and Nevada, representing approximately 260,000 additional patient lives under management.

Speaker #3: We showed our ability to grow and manage industry leading MLR performance under our delegated capitation model in Florida . Set records in part D pharmacy growth De-risked our balance sheet and recorded our first positive adjusted EBITDA quarter as a public company in the fourth quarter .

Daniel Virnich: Stepping back, 2025 was a very productive year for TOI and one where we made progress across multiple areas of the organization. From a financial perspective, we delivered strong top-line growth with revenue increasing approximately 28% year-over-year and surpassing $500 million for the first time in our history. We continued expanding our capitated footprint, initiating 9 new capitated contracts during 2025 in California, Florida, and Nevada, representing approximately 260,000 additional patient lives under management.

Speaker #3: As we enter 2026, our focus is on execution, and we believe we are well positioned to further expand payer partnerships and deliver sustainable profitability over the long term. With that, I'll turn the call over to Rob to review our financial results.

Speaker #3: Rob .

Speaker #2: Thanks , Dan , and good afternoon , everyone . I want to echo Dan's comments on what was a significant year for toy .

Speaker #2: In the fourth quarter , we continued to build momentum across both our fee for service and capitation businesses , as well as dispensing , while at the same time moving toward positive adjusted EBITDA .

Speaker #2: On today's call , I'll start by addressing the expected impact of the Inflation Reduction Act . Then review our key financial highlights for 2025 .

Daniel Virnich: Another key contributor to this growth was our Part D dispensing platform, which remains an important part of our integrated care model as we continue to increase prescription volumes and attachment rates within our network. This segment of our business reached almost $270 million in total revenue and contributed close to $50 million in gross profit for the full year. From an operating standpoint, we continue improving efficiency across the organization. SG&A declined 2% year-over-year, demonstrating the leverage in our model as we scale. During the year, we also outsourced our clinical trials operations, allowing our physicians and care teams to remain focused on delivering high quality clinical care while still being able to direct our patients to the trials they need in our clinics and supporting more rapid growth and multi-market scalability. Finally, we strengthened our balance sheet during the year.

Speaker #2: Walk through our fourth quarter results and finally discuss our guidance and outlook for 2026 and beyond Regarding the Inflation Reduction Act , we expect the impact to Imbruvica in 2026 to be minor , representing an unfavorable impact of less than 1% of total pharmacy revenue and gross margin .

Speaker #2: Importantly , as Imbruvica and additional drugs are subject to maximum fair price negotiations under the IRA , we have multiple levers available to help offset this impact , including but not limited to , optimization of our pharmacy mix via increased utilization of alternative therapies , a function which toy has significant control over through our centralized utilization management process Additionally , the reimbursement shift in certain disease state categories introduced by the IRA allows toy and opportunity to leverage relationships with drug manufacturers and distributors to reassess category economics discussions , which are benefited by improving purchasing power .

Daniel Virnich: During the year, we also outsourced our clinical trials operations, allowing our physicians and care teams to remain focused on delivering high quality clinical care while still being able to direct our patients to the trials they need in our clinics and supporting more rapid growth and multi-market scalability. Finally, we strengthened our balance sheet during the year.

Daniel Virnich: We reduced debt on our convertible preferred note by $24 million and ended the year with $33.6 million in cash after experiencing positive free cash flow in Q4, giving us additional flexibility as we continue to grow the platform. Operationally, we also made meaningful progress expanding our care model. Our delegated capitation partnership with Elevance Health in Florida continued to ramp during Q4 and remains on track to continue expansion across the state in 2026, which would more than double the current partnership. Today, we have approximately 70,000 lives under capitated arrangements within this partnership.

Speaker #2: As we scale as a drug purchasing organization . As a result of the foregoing , we do not expect the IRA specifically to materially alter the long term economics or trajectory of our platform Turning to full year 2025 , the year marked meaningful operational and financial progress for toy .

Speaker #2: We delivered revenue growth of approximately 27.8% year over year from 393.4 million to 502.7 million , driven by continued expansion in both patient volumes and services per patient Our fee for service business grew 9% year over year from 136.2 million to 148.5 million , while our capitation business grew 17.2% year over year from 68.7 million to 80.5 million , driven primarily by the launch of our new delegation model in Florida , which I will expand on more in a moment Pharmacy revenue grew 49.6% year over year , from 179.9 million to 269.2 million , primarily the result of improved attachment of prescriptions to our provider visits in both fee for service and capitation populations , as well as reduced leakage of prescriptions written by toy providers to outside specialty pharmacies The successful launch of our new delegation model in Florida produced over 10 million in new capitated revenue in 2025 , with an annualized run rate of approximately 50 million .

Daniel Virnich: Given the economics of our delegated model, it's also worth highlighting that delegated members represented less than 5% of total capitated lives at the end of 2025, but account for approximately a third of our run rate capitated revenue, reflecting the higher PMPM structure associated with these arrangements and the high utilizing populations they service. In addition to Elevance, we also initiated capitation agreements with Humana and CarePlus in Florida during Q4, further expanding payer partnerships and representing approximately 22,000 additional MA lives in South Florida.

Daniel Virnich: Our Florida oncology network platform also continued to grow with the number of participating providers increasing to approximately 207 physicians and advanced practice providers across our network, supporting what we refer to as our hybrid model of patient care, which allows us to treat our managed populations at a combination of TOI-affiliated, as well as independent clinics, and our employed clinics under our fully delegated network umbrella. Finally, from an organizational standpoint, we strengthened the leadership team substantially in 2025 with the additions of Jeff Langsam as Chief Clinical Officer and Kristen England as Chief Administrative Officer. Both bring significant experience scaling healthcare organizations and will play an important role as we continue expanding our platform and executing on our growth strategy.

Speaker #2: As we enter 2026, we believe this new delegated model enhances TOI's ability to efficiently scale into new markets, while retaining our ability to both directly control clinical utilization as well as deliver our comprehensive oncology model to populations under the delegated contracts.

Daniel Virnich: Finally, from an organizational standpoint, we strengthened the leadership team substantially in 2025 with the additions of Jeff Langsam as Chief Clinical Officer and Kristen England as Chief Administrative Officer. Both bring significant experience scaling healthcare organizations and will play an important role as we continue expanding our platform and executing on our growth strategy.

Speaker #2: We accomplished this by serving patients at a mix of network providers and toy clinics . A dynamic you will hear us refer to as our hybrid model because it utilizes both independent and captive providers in a hybridized deployment .

Speaker #2: This hybrid model allows us to optimize for MLR while balancing capital efficiency and operating leverage , all while delivering maximum savings and minimum time to launch and network disruption to our payer partners .

Daniel Virnich: As we move into 2026, our focus remains on continuing to scale and drive profitability in our value-based care platform so that we can serve more patients and payers across the country with high quality oncology care while improving access to therapeutics and reducing the financial burden of that care. First, we expect continued strong growth in our delegated capitation model, having guided in January to over 80% growth in capitated revenue for the year. Second, we are preparing to launch our proprietary new network portal in Q2, which will further strengthen engagement with both our affiliated and independent providers. The platform will improve visibility into utilization management pathways, support formulary adherence, and help drive continued improvement in our medical loss ratio.

Speaker #2: Most importantly, we ended the year with positive adjusted EBITDA in the fourth quarter, reflecting the operating leverage embedded in our model and the progress we've made toward sustainable profitability. Turning to the fourth quarter, results were consistent with the trends we've discussed throughout the year.

Daniel Virnich: Second, we are preparing to launch our proprietary new network portal in Q2, which will further strengthen engagement with both our affiliated and independent providers. The platform will improve visibility into utilization management pathways, support formulary adherence, and help drive continued improvement in our medical loss ratio.

Speaker #2: Total revenue for the fourth quarter was 142 million , compared to 100.3 million in the prior year period , representing a 41.6% year over year growth .

Speaker #2: That was driven by continued patient growth and pharmacy contribution Patient services revenue , which includes both capitation and fee for service arrangements , totaled 59.8 million , or 42.2% of total revenue , and increased 19.2% year over year .

Daniel Virnich: Importantly, it will also help enable ancillary services engagement such as Part D dispensing adoption across our independent network providers, which remains a meaningful opportunity for incremental growth. Finally, we strengthened our board of directors in Q1 with the additions of Mark Stolper and Kim Tzoumakas. Mark brings significant financial leadership and public markets experience as a longtime CFO of RadNet, while Kim brings deep expertise in oncology and pharmacy services through her prior leadership roles as CEO of VitalOne and 21st Century Oncology, respectively. We believe both will add valuable perspectives as we continue scaling the organization. In summary, 2025 was a foundational year for TOI.

Speaker #2: Within the segment . Fee for service contributed roughly 25.6% of total revenue , and capitation accounted for 16.6% , reflecting the significant recurring nature of patient services revenue and steady patient volumes on which we lay our new capitation contracts , as well as continuous expansion of our fee for service referral base Pharmacy revenue was 81.4 million , representing 57.4% of total revenue , and increased 71.1% year over year , driven by higher prescription volumes and expanded pharmacy attachment .

Daniel Virnich: Mark brings significant financial leadership and public markets experience as a longtime CFO of RadNet, while Kim brings deep expertise in oncology and pharmacy services through her prior leadership roles as CEO of VitalOne and 21st Century Oncology, respectively. We believe both will add valuable perspectives as we continue scaling the organization. In summary, 2025 was a foundational year for TOI.

Speaker #2: Within our clinics , which was a key operational focus for us over the course of the year Turning to gross profit , we reported 22.7 million for the quarter compared to 14.6 million in the fourth quarter of 2020 .

Daniel Virnich: We showed our ability to grow and manage industry-leading MLR performance under our delegated capitation model in Florida, set records in Part D pharmacy growth, de-risked our balance sheet, and recorded our first positive adjusted EBITDA quarter as a public company in Q4. As we enter 2026, our focus is on execution, and we believe we are well-positioned to further expand payer partnerships and deliver sustainable profitability over the long term. With that, I'll turn the call over to Rob to review our financial results. Rob.

Speaker #2: For Gross margin was 16% versus 14.6% in the prior year period , reflecting a year over year margin increase of approximately 140 basis points Patient services gross profit was 7.1 million , up from 4.5 million a year ago , representing a 59.5% year over year increase , with a gross margin of 11.9% , up from 8.9% in the prior year Pharmacy gross profit totaled 14.9 million , compared to 8.1 million in the fourth quarter of 2024 , a 84.7% year over year increase , driven by higher dispensing volumes and improved drug purchasing .

Rob Carter: Thanks, Dan, and good afternoon, everyone. I want to echo Dan's comments on what was a significant year for TOI. In the Q4, we continued to build momentum across both our fee-for-service and capitation businesses, as well as dispensing, while at the same time moving toward positive adjusted EBITDA. On today's call, I'll start by addressing the expected impact of the Inflation Reduction Act, then review our key financial highlights for 2025, walk through our Q4 results, and finally, discuss our guidance and outlook for 2026 and beyond. Regarding the Inflation Reduction Act, we expect the impact to Imbruvica in 2026 to be minor, representing an unfavorable impact of less than 1% of total pharmacy revenue and gross margin.

Robert Carter: Thanks, Dan, and good afternoon, everyone. I want to echo Dan's comments on what was a significant year for TOI. In the Q4, we continued to build momentum across both our fee-for-service and capitation businesses, as well as dispensing, while at the same time moving toward positive adjusted EBITDA. On today's call, I'll start by addressing the expected impact of the Inflation Reduction Act, then review our key financial highlights for 2025, walk through our Q4 results, and finally, discuss our guidance and outlook for 2026 and beyond.

Speaker #2: Pharmacy gross margin increased over 130 basis points from the prior year to 18.3% , reflecting ongoing optimization and commercial drug procurement . Reflecting a focus on leveraging Tui's increasing scale in supply chain operations Turning to operating expenses , excluding depreciation and amortization , the total was 28 million , or 19.7% of revenue , compared to 24.8% of revenue .

Robert Carter: Regarding the Inflation Reduction Act, we expect the impact to Imbruvica in 2026 to be minor, representing an unfavorable impact of less than 1% of total pharmacy revenue and gross margin. Importantly, as Imbruvica and additional drugs are subject to maximum fair price negotiations under the IRA, we have multiple levers available to help offset this impact, including, but not limited to, optimization of our pharmacy mix via increased utilization of alternative therapies, a function which TOI has significant control over through our centralized utilization management process.

Rob Carter: Importantly, as Imbruvica and additional drugs are subject to maximum fair price negotiations under the IRA, we have multiple levers available to help offset this impact, including, but not limited to, optimization of our pharmacy mix via increased utilization of alternative therapies, a function which TOI has significant control over through our centralized utilization management process. Additionally, the reimbursement shift in certain disease state categories introduced by the IRA allows TOI an opportunity to leverage relationships with drug manufacturers and distributors to reassess category economics, discussions which are benefited by TOI's improving purchasing power as we scale as a drug purchasing organization. As a result of the foregoing, we do not expect the IRA specifically to materially alter the long-term economics or trajectory of our platform. Turning to full year 2025, the year marked meaningful operational and financial progress for TOI.

Speaker #2: A reduction of over 500 basis points versus a year ago The decrease in Rsna reflects continued cost , discipline and operating leverage inherent in our model Adjusted EBITDA was 147,000 , improving from -7.8 million in the fourth quarter of 2020 .

Speaker #2: Four . We achieved positive adjusted EBITDA in the fourth quarter , a key milestone as we exit 2025 . Turning to the balance sheet and cash flow , we ended the quarter with 33.6 million in cash and cash equivalents .

Robert Carter: Additionally, the reimbursement shift in certain disease state categories introduced by the IRA allows TOI an opportunity to leverage relationships with drug manufacturers and distributors to reassess category economics, discussions which are benefited by TOI's improving purchasing power as we scale as a drug purchasing organization. As a result of the foregoing, we do not expect the IRA specifically to materially alter the long-term economics or trajectory of our platform. Turning to full year 2025, the year marked meaningful operational and financial progress for TOI.

Speaker #2: Operating cash flow for the quarter was a positive 3.2 million , reflecting investments in drug inventory and working capital . To support our scaling , dispensing activity Now turning to guidance for full year 2026 , we are reiterating guidance provided in January 2026 as follows .

Speaker #2: Revenue in the range of 630 million to 650 million . Approximately 150 million of capitated revenue . Gross profit in the range of 97 million to 107 million .

Rob Carter: We delivered revenue growth of approximately 27.8% year-over-year from $393.4 million to $502.7 million, driven by continued expansion in both patient volumes and services per patient. Our Fee-for-Service business grew 9% year-over-year from $136.2 million to $148.5 million, while our capitation business grew 17.2% year-over-year from $68.7 million to $80.5 million, driven primarily by the launch of our new delegated capitation model in Florida, which I will expand on more in a moment.

Robert Carter: We delivered revenue growth of approximately 27.8% year-over-year from $393.4 million to $502.7 million, driven by continued expansion in both patient volumes and services per patient. Our Fee-for-Service business grew 9% year-over-year from $136.2 million to $148.5 million, while our capitation business grew 17.2% year-over-year from $68.7 million to $80.5 million, driven primarily by the launch of our new delegated capitation model in Florida, which I will expand on more in a moment.

Speaker #2: Adjusted EBITDA is in the range of $0 to $9 million, and free cash flow is in the range of negative $15 million to $5 million. I want to highlight that the first quarter is seasonally our lowest due to patients' deductible resets and annual drug price increases that are not immediately reflected in reimbursement rates.

Speaker #2: As pharmaceutical reimbursement adjustments operate on a lagged basis for pricing While we always worked hard to mitigate these two factors , naturally lead us to anticipate an adjusted EBITDA loss for the first quarter .

Rob Carter: Pharmacy revenue grew 49.6% year-over-year from $179.9 million to $269.2 million, primarily the result of improved attachment of prescriptions to our provider visits in both fee-for-service and capitated populations, as well as reduced leakage of prescriptions written by TOI providers to outside specialty pharmacies. The successful launch of our new delegated model in Florida produced over $10 million in new capitated revenue in 2025, with an annualized run rate of approximately $50 million as we enter 2026. We believe this new delegated model enhances TOI's ability to efficiently scale in new markets while retaining our ability to both directly control clinical utilization as well as deliver our comprehensive oncology model to populations under the delegated contracts.

Robert Carter: Pharmacy revenue grew 49.6% year-over-year from $179.9 million to $269.2 million, primarily the result of improved attachment of prescriptions to our provider visits in both fee-for-service and capitated populations, as well as reduced leakage of prescriptions written by TOI providers to outside specialty pharmacies.

Speaker #2: Based on these factors , we anticipate first quarter adjusted EBITDA to be between a loss of 3 to 1 million with continued momentum over the course of the year .

Speaker #2: On a year over year comparison basis , the first quarter of 2025 included a one time benefit of 1.6 million based on a renegotiated drug distribution agreement .

Robert Carter: The successful launch of our new delegated model in Florida produced over $10 million in new capitated revenue in 2025, with an annualized run rate of approximately $50 million as we enter 2026. We believe this new delegated model enhances TOI's ability to efficiently scale in new markets while retaining our ability to both directly control clinical utilization as well as deliver our comprehensive oncology model to populations under the delegated contracts.

Speaker #2: On the pharmacy side, we are assuming performance in line with the second half 2025 revenue run rate of approximately $27 million per month, plus a modest incremental growth of 3 to 5% from attachment to new capitation lives.

Speaker #2: We are capturing, in TOI clinics, through 2026. We believe this capture of capitation lives in TOI clinics is the beginning of a multi-year penetration narrative.

Speaker #2: As we optimize toy captive clinic footprint relative to network providers for populations managed under our delegated model . As previously , as previously discussed , as part of our hybrid strategy with respect to overall capitation growth , our outlook remains measured and does not include any contribution from new go get contract wins .

Rob Carter: We accomplish this by serving patients at a mix of network providers and TOI clinics, a dynamic you will hear us refer to as our hybrid model because it utilizes both independent and captive providers in a hybridized deployment. This hybrid model allows us to optimize for MLR while balancing capital efficiency and operating leverage, all while delivering maximum savings, minimum time to launch, and network disruption to our payer partners. Most importantly, we ended the year with positive adjusted EBITDA in Q4, reflecting the operating leverage embedded in our model and the progress we've made towards sustainable profitability. Turning to Q4, results were consistent with the trends we've discussed throughout the year.

Robert Carter: We accomplish this by serving patients at a mix of network providers and TOI clinics, a dynamic you will hear us refer to as our hybrid model because it utilizes both independent and captive providers in a hybridized deployment. This hybrid model allows us to optimize for MLR while balancing capital efficiency and operating leverage, all while delivering maximum savings, minimum time to launch, and network disruption to our payer partners.

Speaker #2: Gross profit is expected to grow slightly ahead of revenue , with gross margins improving by 100 to 200 basis points , primarily the result of improving direct medical expenses in relation to revenue , which is principally supported by improvement in drug spend .

Robert Carter: Most importantly, we ended the year with positive adjusted EBITDA in Q4, reflecting the operating leverage embedded in our model and the progress we've made towards sustainable profitability. Turning to Q4, results were consistent with the trends we've discussed throughout the year.

Speaker #2: The result of our focus on both commercial procurement and clinical utilization management is expected to trend down modestly as a percentage of revenue to approximately 16% , reflecting operating leverage .

Rob Carter: Total revenue for Q4 was $142 million, compared to $100.3 million in the prior year period, representing a 41.6% year-over-year growth that was driven by continued patient growth and pharmacy contribution. Patient services revenue, which includes both capitation and Fee-for-Service arrangements, totaled $59.8 million or 42.2% of total revenue and increased 19.2% year-over-year. Within the segment, Fee-for-Service contributed roughly 25.6% of total revenue and capitation accounted for 16.6%, reflecting the significant recurring nature of patient services revenue and steady patient volumes on which we layer new capitation contracts as well as a continuous expansion of our Fee-for-Service referral base.

Robert Carter: Total revenue for Q4 was $142 million, compared to $100.3 million in the prior year period, representing a 41.6% year-over-year growth that was driven by continued patient growth and pharmacy contribution. Patient services revenue, which includes both capitation and Fee-for-Service arrangements, totaled $59.8 million or 42.2% of total revenue and increased 19.2% year-over-year.

Speaker #2: Though we will continue to prioritize our growth initiatives as we invest for growth , we remain focused on capital discipline and cash generation .

Speaker #2: We expect to achieve free cash flow positivity by end of 2026 , supported by EBITDA growth and improving working capital dynamics . With that , I'll turn the call over to Dan for closing remarks

Robert Carter: Within the segment, Fee-for-Service contributed roughly 25.6% of total revenue and capitation accounted for 16.6%, reflecting the significant recurring nature of patient services revenue and steady patient volumes on which we layer new capitation contracts as well as a continuous expansion of our Fee-for-Service referral base.

Speaker #3: Thanks , Rob . In closing , 2025 represented an important step forward for toy . We delivered impressive growth , strengthen our balance sheet and exited the year with positive adjusted EBITDA .

Speaker #3: While expanding the number of patients across the country that come to us for high quality cancer care in the communities that we serve .

Speaker #3: As we look ahead, our guidance reflects a prudent and disciplined approach, while still positioning the company to invest in growth and unlock the long-term value of our platform. With that, I'll turn the call back to the operator for questions.

Rob Carter: Pharmacy revenue was $81.4 million, representing 57.4% of total revenue, and increased 71.1% year-over-year, driven by higher prescription volumes and expanded pharmacy attachment within our clinics, which was a key operational focus for us over the course of the year. Turning to gross profit, we reported $22.7 million for the quarter, compared to $14.6 million in Q4 2024. Gross margin was 16% versus 14.6% in the prior year period, reflecting a year-over-year margin increase of approximately 140 basis points.

Robert Carter: Pharmacy revenue was $81.4 million, representing 57.4% of total revenue, and increased 71.1% year-over-year, driven by higher prescription volumes and expanded pharmacy attachment within our clinics, which was a key operational focus for us over the course of the year. Turning to gross profit, we reported $22.7 million for the quarter, compared to $14.6 million in Q4 2024. Gross margin was 16% versus 14.6% in the prior year period, reflecting a year-over-year margin increase of approximately 140 basis points.

Speaker #3: Operator .

Speaker #1: Thank you . We will now conduct a question and answer session . If you would like to ask a question , please press star one on your telephone keypad .

Speaker #1: A confirmation tone will indicate your line is in the question queue . You may press star two to remove yourself from the queue .

Speaker #1: For participants using speaker equipment, it may be necessary to pick up your handset before pressing the star keys. Once again, that's star one at this time.

Speaker #1: One moment while we poll for the first question. The first question comes from David Lawson with BTIG. Please proceed.

Rob Carter: Patient services gross profit was $7.1 million, up from $4.5 million a year ago, representing a 59.5% year-over-year increase with a gross margin of 11.9%, up from 8.9% in the prior year. Pharmacy gross profit totaled $14.9 million compared to $8.1 million in Q4 2024, an 84.7% year-over-year increase driven by higher dispensing volumes and improved drug purchasing. Pharmacy gross margin increased over 130 basis points from the prior year to 18.3%. Reflecting ongoing optimization in commercial drug procurement, a focus on leveraging TOI's increasing scale in supply chain operations.

Robert Carter: Patient services gross profit was $7.1 million, up from $4.5 million a year ago, representing a 59.5% year-over-year increase with a gross margin of 11.9%, up from 8.9% in the prior year. Pharmacy gross profit totaled $14.9 million compared to $8.1 million in Q4 2024, an 84.7% year-over-year increase driven by higher dispensing volumes and improved drug purchasing. Pharmacy gross margin increased over 130 basis points from the prior year to 18.3%. Reflecting ongoing optimization in commercial drug procurement, a focus on leveraging TOI's increasing scale in supply chain operations.

Speaker #4: Hi . Congratulations on the good quarter . And year I guess for your dispensing revenue in the quarter . It came in a lot higher than what we were modeling .

Speaker #4: Just any thoughts or color around the driver of that, and what we should expect for '26? Thank you.

Speaker #3: Yeah . Hey , Dave . Thanks . Thanks for the great question Yeah . The fourth quarter was a very strong quarter in terms of dispensing revenue and performance .

Speaker #3: And that was really driven by two things . One was ongoing operational execution in terms of mitigating leakage of scripts outside of our pharmacies .

Rob Carter: Turning to operating expenses, excluding depreciation and amortization, the total SG&A was $28 million, or 19.7% of revenue, compared to 24.8% of revenue, a reduction of over 500 basis points versus a year ago. The decrease in SG&A reflects continued cost discipline and operating leverage inherent in our models. Adjusted EBITDA was $147,000, improving from negative $7.8 million in Q4 2024. We achieved positive adjusted EBITDA in Q4, a key milestone as we exit 2025. Turning to the balance sheet and cash flow, we ended the quarter with $33.6 million in cash and cash equivalents. Operating cash flow for the quarter was a positive $3.2 million, reflecting investments in drug inventory and working capital to support our scaling dispensing activity. Now turning to guidance.

Robert Carter: Turning to operating expenses, excluding depreciation and amortization, the total SG&A was $28 million, or 19.7% of revenue, compared to 24.8% of revenue, a reduction of over 500 basis points versus a year ago. The decrease in SG&A reflects continued cost discipline and operating leverage inherent in our models.

Speaker #3: And dispensaries , where we could fill the medication . very strong patient encounter growth related to our capitated contract growth across markets

Speaker #4: Okay . And then did I hear you say that you're going to double the size of your relevance contract in the state of Florida in 26 ?

Speaker #3: Yes, that's our goal.

Robert Carter: Adjusted EBITDA was $147,000, improving from negative $7.8 million in Q4 2024. We achieved positive adjusted EBITDA in Q4, a key milestone as we exit 2025. Turning to the balance sheet and cash flow, we ended the quarter with $33.6 million in cash and cash equivalents. Operating cash flow for the quarter was a positive $3.2 million, reflecting investments in drug inventory and working capital to support our scaling dispensing activity. Now turning to guidance.

Speaker #4: Okay . And then is the Humana contract . Is that a new contract signed ? In the fourth quarter or in the Or in the first quarter ?

Speaker #4: You did not have a deal with Humana previously, is that correct?

Speaker #3: Yeah, that went effective in the fourth quarter. And that was for both Humana and CarePlus for Medicare Advantage lives in South Florida, on behalf of medical groups that they partner with.

Speaker #4: Could you just give us a sense for the size of , I guess , the Tam for L'avance or Humana ? Like how much revenue or how many lives could you potentially grow into in those states for Elvanse and Humana alone ?

Rob Carter: For full year 2026, we are reiterating guidance provided in January 2026 as follows. Revenue in the range of $630 to 650 million, approximately $150 million of capitated revenue. Gross profit in the range of $97 to 107 million. Adjusted EBITDA in the range of $0 to 9 million. Free cash flow in the range of negative $15 to 5 million. I want to highlight that the first quarter is seasonally our lowest due to patients' deductible resets and annual drug price increases that are not immediately reflected in reimbursement rates, as pharmaceutical reimbursement adjustments operate on a lagged basis for pricing. While we always worked hard to mitigate these two factors naturally lead us to anticipate an adjusted EBITDA loss for the first quarter.

Robert Carter: For full year 2026, we are reiterating guidance provided in January 2026 as follows. Revenue in the range of $630 to 650 million, approximately $150 million of capitated revenue. Gross profit in the range of $97 to 107 million. Adjusted EBITDA in the range of $0 to 9 million. Free cash flow in the range of negative $15 to 5 million.

Speaker #4: I would imagine it's pretty significant.

Speaker #3: Yeah . I mean , there's publicly available data on Emmaa penetration in Florida by payer , which if you look at that versus our current capitated book across the payers that we partner with in that state is , you know , many multiples of our current capitated revenue .

Robert Carter: I want to highlight that the first quarter is seasonally our lowest due to patients' deductible resets and annual drug price increases that are not immediately reflected in reimbursement rates, as pharmaceutical reimbursement adjustments operate on a lagged basis for pricing. While we always worked hard to mitigate these two factors naturally lead us to anticipate an adjusted EBITDA loss for the first quarter.

Speaker #3: So just tremendous opportunity . And really what excites us a lot about that market is , you know , many , many years ahead of growth for toy .

Speaker #3: As we continue to execute

Speaker #4: Okay . And then just one more quick one for me before I hop back in the queue for the capitated revenue . How are your margins looking and how are volumes and cost trend looking relative to expectations ?

Rob Carter: Based on these factors, we anticipate Q1 adjusted EBITDA to be between a loss of $3 to $1 million, with continuing momentum over the course of the year. On a year-over-year comparison basis, the first quarter of 2025 included a one-time benefit of $1.6 million based on a renegotiated drug distribution agreement. On the pharmacy side, we are assuming performance in line with the second half 2025 revenue run rate of approximately $27 million per month, plus a modest incremental growth of 3% to 5% from attachment to new capitation lives we are capturing in TOI clinics through 2026.

Robert Carter: Based on these factors, we anticipate Q1 adjusted EBITDA to be between a loss of $3 to $1 million, with continuing momentum over the course of the year. On a year-over-year comparison basis, the first quarter of 2025 included a one-time benefit of $1.6 million based on a renegotiated drug distribution agreement. On the pharmacy side, we are assuming performance in line with the second half 2025 revenue run rate of approximately $27 million per month, plus a modest incremental growth of 3% to 5% from attachment to new capitation lives we are capturing in TOI clinics through 2026.

Speaker #4: I guess for both the fourth quarter and the first couple of months of 26 ?

Speaker #3: Hey Dave , it's Rob

Speaker #2: Performance both in terms of volume and MLR is is coming in exactly as we expect it to , to be , you know , as you know , we have real time views into our claims .

Speaker #2: And so , you know , our ability to , to manage that MLR is materially higher than what you see in the market .

Rob Carter: We believe this capture of capitation lives in TOI clinics is the beginning of a multi-year penetration narrative as we optimize TOI's captive clinic footprint relative to network providers for populations managed under our delegated model as previously discussed as part of our hybrid strategy. With respect to overall capitation growth, our outlook remains measured and does not include any contribution from new GoGet contract wins. Gross profit is expected to grow slightly ahead of revenue, with gross margins improving by 100 to 200 basis points, primarily the result of improving direct medical expenses in relation to revenue, which is principally supported by improvement in drug spend, the result of our focus on both commercial procurement and clinical utilization management.

Robert Carter: We believe this capture of capitation lives in TOI clinics is the beginning of a multi-year penetration narrative as we optimize TOI's captive clinic footprint relative to network providers for populations managed under our delegated model as previously discussed as part of our hybrid strategy. With respect to overall capitation growth, our outlook remains measured and does not include any contribution from new GoGet contract wins.

Speaker #2: So no surprises right now. Things are looking quite good.

Speaker #4: And then for the lives that started in for Q of 25 , would you expect to get to say an 85% MLR by late 26 .

Speaker #4: Is that fair

Speaker #2: So we have we have two types of contracts for the delegated contracts that launched in Florida . Yes . I think that's fair .

Robert Carter: Gross profit is expected to grow slightly ahead of revenue, with gross margins improving by 100 to 200 basis points, primarily the result of improving direct medical expenses in relation to revenue, which is principally supported by improvement in drug spend, the result of our focus on both commercial procurement and clinical utilization management.

Speaker #2: 85% MLR within the contracts that launched . We're also some neural network contracts in California , and we would expect , as we mentioned , in our in our earnings material , a lower MLR with a slightly faster ramp to that MLR as well .

Rob Carter: SG&A is expected to trend down modestly as a percentage of revenue to approximately 16%, reflecting operating leverage, though we will continue to prioritize our growth initiatives. As we invest for growth, we remain focused on capital discipline and cash generation. We expect to achieve free cash flow positivity by end of 2026, supported by EBITDA growth and improving working capital dynamics. With that, I'll turn the call over to Dan for closing remarks.

Robert Carter: SG&A is expected to trend down modestly as a percentage of revenue to approximately 16%, reflecting operating leverage, though we will continue to prioritize our growth initiatives. As we invest for growth, we remain focused on capital discipline and cash generation. We expect to achieve free cash flow positivity by end of 2026, supported by EBITDA growth and improving working capital dynamics. With that, I'll turn the call over to Dan for closing remarks.

Speaker #4: And , and then do the plans , prefer the narrow networks or the broader networks ? Do they have a preference Just any color .

Speaker #4: There would be helpful

Speaker #3: Yeah , absolutely . It's really two different customer types . So . Plans for the most part are delegated capitation model where they prefer a network that is open , inclusive of both our key employee clinics as well as the oncology network that we contract .

Daniel Virnich: Thanks, Rob. In closing, 2025 represented an important step forward for TOI. We delivered impressive growth, strengthened our balance sheet, and exited the year with positive adjusted EBITDA while expanding the number of patients across the country that come to us for high-quality cancer care in the communities that we serve. As we look ahead, our guidance reflects a prudent and disciplined approach while still positioning the company to invest in growth and unlock the long-term value of our platform. With that, I'll turn the call back to the operator for questions. Operator?

Speaker #3: And Owen , after delegation , the narrow network legacy , capitation model really applies to our customers that are risk bearing medical groups that are not keen , licensed , that , again , prefer fully narrowing the network to one oncology provider .

Speaker #4: Okay , great quarter . I'll hop back in the queue and I might follow up at later on . Thanks

Speaker #3: Thanks , Dave

Speaker #1: The next question comes from Juan V with B Riley , please proceed .

Speaker #5: Thank you for taking our questions . Rob or Dan , based on the guidance , you will have a meaningful growth in the capitated contracts in 2026 .

Operator: Thank you. We will now conduct a question-and-answer session. If you would like to ask a question, please press star one on your telephone keypad. A confirmation tone will indicate your line is in the question queue. You may press star two to remove yourself from the queue. For participants using speaker equipment, it may be necessary to pick up your handset before pressing the star keys. Once again, that's star one at this time. One moment while we poll for the first question. The first question comes from David Larsen with BTIG. Please proceed.

Speaker #5: Almost double their . As you ramp up the capitated contracts in delegated network . Should we anticipate a dip in profit margin in mid 2026 because of this patient transition period

Operator: For participants using speaker equipment, it may be necessary to pick up your handset before pressing the star keys. Once again, that's star one at this time. One moment while we poll for the first question. The first question comes from David Larsen with BTIG. Please proceed.

Speaker #2: Yeah yeah yeah . Hey , Johan , it's Rob . Yes . Specific to the delegated contracts . Yes , yes . You'll probably see a slightly higher MLR again , just specific to those contracts as it relates to , you know , total weighted gross margin percentage .

David Larsen: Hi, congratulations on the good quarter and year. I guess for your dispensing revenue in the quarter, it came in a lot higher than what we were modeling. Just any thoughts or color around the driver of that and what we should expect for 2026? Thank you.

Speaker #2: No, I don't think that you're going to see a dip at that aggregate level.

Speaker #5: Got it . And then on the press release , I think the latest number of affiliated and network clinics are 146 . Can you share more details of that ?

Daniel Virnich: Yeah. Hey, Dave. Thanks for the great question. Yeah, Q4 was a very strong quarter in terms of dispensing revenue and performance, and that was really driven by two things. One was ongoing operational execution in terms of mitigating leakage of scripts outside of our pharmacies and dispensaries where we could fill the medication. Two was very strong patient encounter growth related to our capitated contract growth across markets.

Speaker #5: I think the last number we saw was 86.

Speaker #3: Yeah . So yeah , absolutely . So we've got our 80 employee sites of care across five states . The network is actually larger than that .

Speaker #3: So, it's over 200 by headcount in the network in Florida now, so that brings our totals up close to 300 combined.

David Larsen: Okay. Did I hear you say that you're gonna double the size of your Elevance Health contract in the state of Florida in 2026?

Speaker #5: Got it. And then, one last question related to the CAR-T. I think in last June, the FDA removed the Risk Evaluation and Mitigation Strategy.

Daniel Virnich: Yes, that's our goal.

Speaker #5: The Rems requirement for all currently approved car T therapies is your neck . So in your next contract , updating and signing . Do you think or do you anticipate that you will need to add car t into your treatment offerings or contract ?

David Larsen: Okay. Then is the Humana contract, is that a new contract signed in Q4 or in Q1? You did not have a deal with Humana previously. Is that correct?

Daniel Virnich: Yeah, that went effective in Q4, and that was for both Humana and CarePlus for Medicare Advantage lives in South Florida on behalf of risk-bearing medical groups that they partner with.

Speaker #5: Or have you thought about that

Speaker #3: No . You know , we across the board do not take risk on car T simply because it is a very low incidence therapy .

David Larsen: Could you just give us a sense for the size of, I guess, the TAM for Elevance Health or Humana? Like, how much revenue or how many lives could you potentially grow into in those states for Elevance Health and Humana alone? I would imagine it's pretty significant.

Speaker #3: And then , you know , not . Offered currently in a high number of locations in the community . There are some interesting businesses out there that are trying to develop models for car t therapy in the community .

Speaker #3: We view that as very positive for patients . If that were to happen in the future , and certainly expanding access , if the if the utilization and indications for that therapy grow over time is definitely something we would consider adding to our value based contracting platform .

Daniel Virnich: Yeah. I mean, there's publicly available data on MA penetration in Florida by payer, which, if you look at that versus our current capitated book across the payers that we partner with in that state, is, you know, many multiples of our current capitated revenue. Just tremendous opportunity and really what excites us a lot about that market is, you know, many years ahead of growth for TOI as we continue to execute.

Speaker #3: But as of right now , we do not take risk on car t .

Speaker #5: Got it. I recall back.

Speaker #1: The next question comes from Matthew Shay with Needham and Company. Please proceed.

Speaker #6: Hey , thanks for taking the question and congrats on a strong finish to the year here Wanted to start with maybe double clicking on the wins in the quarter .

David Larsen: Okay. Just one more quick one for me before I hop back on the queue. For the capitated revenue, how are your margins looking and how are volumes and cost trend looking relative to expectations, I guess, for both Q4 and the first couple of months of 2026?

Speaker #6: So, one of the deals with Humana and CarePlus, anything you can share on those deals? Were those competitive processes? And I believe Humana represents an expansion deal.

Speaker #6: So, any commentary on how success with the prior markets led to expansion would be helpful? And for CarePlus, I believe that's a net new logo.

Rob Carter: Hey, Dave, it's Rob. Performance both in terms of volume and MLR is coming in exactly as we expect it to be. You know, as you know, we have real-time views into our claims, and so you know, our ability to manage that MLR is materially higher than what you see in the market. No surprises right now. Things are looking quite good.

Robert Carter: Hey, Dave, it's Rob. Performance both in terms of volume and MLR is coming in exactly as we expect it to be. You know, as you know, we have real-time views into our claims, and so you know, our ability to manage that MLR is materially higher than what you see in the market. No surprises right now. Things are looking quite good.

Speaker #6: So would love to hear if there if they were managing on or how they were managing oncology prior . And ultimately , how did they land on toy ?

Speaker #3: Yeah , thanks for that . Great question . Yes . So both actually the , the patient's that we have now capitated through Humana and Careplus are net new payer partner ads .

Speaker #3: They are both in Florida in South Florida , specifically those are Medicare Advantage populations delegated to restrain medical groups that they partner with in that market .

David Larsen: for the lives that started in Q4 of 2025, would you expect to get to, say, an 85% MLR by late 2026? Is that fair?

Speaker #3: And , you know , as far as the incumbent oncology provider for those populations , we can't really comment on that . But I will say that the reason why we were able to win that business was , again , sort of our reputation for providing access and high quality care and really coordinating closely with referring primary care physicians , which is what led to sort of the initial outreach .

Rob Carter: We have two types of contracts. For the delegated contracts that launched in Florida, yes, I think that's fair, 85% MLR. Within the contracts that launched were also some narrow network contracts in California. We would expect, as we mentioned in our earnings material, a lower MLR with a slightly faster ramp to that MLR as well.

Robert Carter: We have two types of contracts. For the delegated contracts that launched in Florida, yes, I think that's fair, 85% MLR. Within the contracts that launched were also some narrow network contracts in California. We would expect, as we mentioned in our earnings material, a lower MLR with a slightly faster ramp to that MLR as well.

Speaker #3: But we're really excited about both of those relationships and our partnerships with their risk-bearing medical group constituents in that market.

Speaker #6: Got it . Appreciate that . Maybe hitting on AI , you know , last quarter , you laid out the three buckets of RCM prior auth and patient call center and sounds like prior auth is the furthest along with your early estimates suggesting 2 million .

David Larsen: Do the plans prefer the narrow networks or the broader networks? Do they have a preference? Just any color there would be helpful.

Speaker #6: I believe in , in operating expense efficiencies . What are you assuming in terms in the in the 2026 guide in terms of AI related efficiencies ?

Daniel Virnich: Yeah, absolutely. It's really two different customer types. Plans, for the most part, is our delegated capitation model, where they prefer a network that is open, inclusive of both our TOI employed clinics as well as the oncology network that we contract and own after delegation. The narrow network legacy capitation model really applies to our customers that are risk-bearing medical groups with a Knox-Keene license, that, again, prefer fully narrowing the network to one oncology provider.

Speaker #6: And should we expect majority of the near unlock to remain focused on prior auth or any update on on RCM or call center ?

Speaker #3: Yeah . Yeah , absolutely . Thanks . That's a great question . So as we mentioned in our last earnings call , we expect in 2026 , the impact of AI related efficiencies across prior authorization , call center and RCM to generate about $2 million in a savings specific to the portions of those departments that they are going to help augment .

David Larsen: Okay, great quarter. I'll hop back in the queue, and I might follow up later on. Thanks.

Speaker #3: We really believe we're just starting to scratch the surface on the use cases and capabilities of, and our business model, which is just very well suited to integrate in a number of different aspects.

Daniel Virnich: Thanks, Dave.

Operator: The next question comes from Yuan Zhi with B. Riley. Please proceed.

Yuan Zhi: Thank you for taking our questions. Rob or Dan, based on the guidance, you will have a meaningful growth in the capitated contracts in 2026, almost double there. As you ramp up the capitated contracts in delegated network, should we anticipate a dip in profit margins in mid-2026 because of this, patient transition period?

Speaker #3: So that savings and efficiency generated over time is going to expand . We're also seeing some tremendous results in terms of metrics that impact patient care and deliver , frankly , better , more er , free patient care as it relates to things like prior authorization , turnaround time , you know , call center responsiveness and key call center KPIs , etc.

Speaker #3: . So , you know , it's really exciting . It's on track and sort of our 2026 estimates in terms of savings impact are on track and haven't changed .

Rob Carter: Yeah. Hey, Yuan, it's Rob. Yes, specific to the delegated contracts, yes. Yes, you'll probably see a slightly higher MLR, again, just specific to those contracts. As it relates to, you know, total weighted gross margins percentage, no, I don't think that you're gonna see a dip at that aggregate level.

Robert Carter: Yeah. Hey, Yuan, it's Rob. Yes, specific to the delegated contracts, yes. Yes, you'll probably see a slightly higher MLR, again, just specific to those contracts. As it relates to, you know, total weighted gross margins percentage, no, I don't think that you're gonna see a dip at that aggregate level.

Speaker #6: Okay , great . Maybe last one for me and then I'll hop back in the queue . Appreciate you laying out the building blocks for the guidance .

Speaker #6: I guess as we're thinking about next year, as we distill the pieces you gave us, we have $150 million of capitated revenue.

Speaker #6: And then using the 27 million per month for pharmacy with modest growth , you get to like 330 and change for dispensary , which leaves about 150 million of change , or 150 million in change for fee for service revenue , which based on where you finished 2025 , implies a effectively like flat to low single digit fee for service growth .

Yuan Zhi: Got it. On the press release, I think the latest number of affiliated and network clinics are 146. Can you share more details of that? I think the last number what we saw was 86.

Daniel Virnich: Yeah, absolutely. We've got our 80 employed sites of care across five states. The network is actually larger than that, it's over 200 by head count in the network in Florida now. It brings our totals up close to 300 combined.

Speaker #6: And I know in the past you've talked about this segment growing in line with the market . Call it high single digits . So maybe just help us unpack the assumptions in the fee for service revenue outlook .

Speaker #2: Yeah . Hey man , it's Rob . So I think the dynamic that you're seeing here is really about the sheer volume of capitated lives that are coming under management with that , and especially in markets like Florida , there's going to be some minor cannibalization of deeper service volumes .

Yuan Zhi: Got it. One last question related to the CAR T. I think in last June, the FDA removed the risk evaluation and mitigation strategy, the REMS, requirement for all currently approved CAR T therapies. In your next contract updating and defining, do you think or do you anticipate that you will need to add CAR T into your treatment offerings or contract, or have you thought about that?

Speaker #2: And so, that's a little bit of the impact that you see there. You know, beyond that, we do expect to continue to see organic growth from our own practice efforts.

Speaker #2: A lot of the growth that we saw in 2025 was driven by ramping new markets like Florida and Oregon . And so as Florida and Oregon continue to mature , some of that organic growth is is going to erode slightly .

Daniel Virnich: No, you know, we across the board do not take risk on CAR T simply because it is a very low incidence therapy and then you know not offered currently in high number of locations in the community. There are some interesting businesses out there that are trying to develop models for CAR T therapy in the community. We view that as very positive for patients if that were to happen in the future. Certainly expanding access if the utilization and indications for that therapy grow over time is definitely something we would consider adding to our value-based contracting platform. As of right now, we do not take risks on CAR T.

Speaker #2: But, you know, the main area of focus continues to be the capitated revenue line, as well as the attachment from pharmacy.

Speaker #2: And we're very excited about the growth there .

Daniel Virnich: We view that as very positive for patients if that were to happen in the future. Certainly expanding access if the utilization and indications for that therapy grow over time is definitely something we would consider adding to our value-based contracting platform. As of right now, we do not take risks on CAR T.

Speaker #6: Okay . That's great color . Thanks , guys . I'll hop back in the queue . Thanks , Matt .

Speaker #1: The next question is a follow up from David Lawson with Btig . Please proceed .

Speaker #4: Can you talk a little bit about your expectations for S , G and A in 2026 ? It looks like for the year as a percentage of revenue , it improved by 642 basis points Just any any thoughts on on how sG&A should trend in 26 as a percentage of revenue ?

Yuan Zhi: Got it. I will hop back on another queue.

Operator: The next question comes from Matthew Shea with Needham & Company. Please proceed.

Matthew Shea: Hey, thanks for taking the question and congrats on a strong finish to the year here. Wanted to start with maybe double-clicking on the wins in the quarter. Won the deals with Humana and CarePlus. Anything you can share on those deals? Were those competitive processes? I believe Humana represents an expansion deal. Any commentary on how success with the prior markets led to expansion would be helpful. For CarePlus, I believe that's a net new logo. Would love to hear how they were managing oncology prior, and ultimately, how did they land on TOI?

Speaker #4: Should we see another significant improvement there ?

Speaker #2: You will see improvements not to that to that degree , as we talked about in the script , there is some investment going on for growth .

Speaker #2: The level of risk that we're taking at this point , you know , as measured by by lives under management , which is represented by that significant percent growth in the capitated revenue line requires some growth .

Speaker #2: But yes , you'll continue to see the scale there . That's something that Dan and I are keenly focused on and aware of , and you'll you'll continue to see our discipline in that area

Daniel Virnich: Hi, Matt. Thanks for this. A great question. Yes. So, both actually the patients that we have now capitated through Humana and CarePlus are net new care partner adds. They're both in Florida, in South Florida specifically. Those are Medicare Advantage populations delegated to risk-bearing medical groups that they partner with in that market. You know, as far as the incumbent oncology provider for those populations, we can't really comment on that, but I will say that the reason why we were able to win that business was, again, sort of our reputation for providing access and high-quality care and really coordinating closely with referring primary care physicians, which is what led to sort of the initial outreach.

Speaker #4: And free cash flow is expected to be positive in 26 .

Speaker #2: Exiting and second half of the year . Yes .

Speaker #4: Okay. And then the fee-for-service revenue.

Daniel Virnich: You know, as far as the incumbent oncology provider for those populations, we can't really comment on that, but I will say that the reason why we were able to win that business was, again, sort of our reputation for providing access and high-quality care and really coordinating closely with referring primary care physicians, which is what led to sort of the initial outreach. We're really excited about both of those relationships and our partnerships with their risk-bearing medical group constituents in that market.

Speaker #3: Dave, are you still there? I think we might have lost audio on Dave.

Speaker #1: Okay. The next question comes from Juan Z. That would be Riley. Please proceed.

Speaker #5: Thanks for taking our question. So, for your $150 million revenue guidance for the contract, can you talk about the underlying assumptions there?

Daniel Virnich: We're really excited about both of those relationships and our partnerships with their risk-bearing medical group constituents in that market.

Speaker #5: So right now you are in five markets in Florida . Are you expanding to expand further and how the dedicated model there will contribute to this growth , meaningful growth in 2026 ?

Matthew Shea: Got it. Appreciate that. Maybe hitting on AI. You know, last quarter you laid out the three buckets of RCM, prior authorization, and patient call center, and it sounds like prior authorization is the furthest along with your early estimates suggesting $2 million, I believe, in operating expense efficiencies. What are you assuming in the 2026 guide in terms of AI-related efficiencies, and should we expect majority of the near term unlock to remain focused on prior authorization, or any update on RCM or call center?

Speaker #2: Yeah . So as we commented on in the script , we've got about $50 million of run rate revenue coming from our Florida based delegated contracts .

Speaker #2: So , you know , beyond that , we have a healthy pipeline with an existing markets . And so the simple answer is no , we don't need to expand beyond the markets we're in to hit that number .

Speaker #2: We are opportunistic about growth . And so with the right opportunity comes for that expansion , then we'll obviously take a very serious look at that

Daniel Virnich: Yeah. Yeah, absolutely. Thanks. That's a great question. As you mentioned in our last earnings call, we expect in 2026 the impact of AI-related efficiencies across prior authorization, call center, and RCM to generate about $2 million in SG&A savings specific to the portions of those departments that they are going to help augment. We really believe we're just starting to scratch the surface on the use cases and capabilities of agentic AI in our business model, which is just very well suited to integration in a number of different aspects. That savings and efficiency generated over time is going to expand.

Speaker #7: Yeah . Got it

Speaker #1: Once again, to ask a question, that's star one on your telephone keypad. The next question is a question from Matthew Shay with Needham and Company.

Speaker #1: Please proceed

Speaker #6: Hey , thanks for letting me back in . I wanted to maybe take a step back and just ask a bit of a higher level question .

Daniel Virnich: We really believe we're just starting to scratch the surface on the use cases and capabilities of agentic AI in our business model, which is just very well suited to integration in a number of different aspects. That savings and efficiency generated over time is going to expand.

Speaker #6: You know , with the the Medicare advance rate notice for 2027 , we effectively saw the whole value based care sell off . You know , yourselves included .

Speaker #6: Although to to a lesser extent , maybe just speak to toys positioning in a potentially lower rate environment . Obviously , payers have already been struggling with oncology trends .

Daniel Virnich: We're also seeing just some tremendous results in terms of metrics that impact patient care and deliver, frankly, better, more error-free patient care as it relates to things like prior authorization turnaround time, you know, call center responsiveness, and key call center KPIs, etc. You know, it's really exciting. It's on track and sort of our 2026 estimates in terms of savings impact are on track and haven't changed.

Speaker #6: So I would expect demand would only accelerate in a time when margins are tighter, but would love to kind of get your thoughts on that topic.

Speaker #3: Yeah , absolutely . Thanks , Matt . That's actually a very important question and something that we continue to try to drive clarity with our investors on , which is the , the emmaa rate cycle and sort of pressure that you've seen health plans and , you know , full risk medical groups that are getting a percent of premium face is actually a tailwind for toy .

Matthew Shea: Okay, great. Maybe last one for me, and then I'll hop back in the queue. Appreciate you laying out the building blocks for the guidance. I guess, as we're thinking about next year, as we distill the pieces you gave us, we have $150 million of capitated revenue, and then using the $27 million per month for pharmacy with modest growth, you get to, like, 330 and change for dispensary, which leaves about $150 million of change or $150 million in change for fee-for-service revenue, which based on where you finish 2025 implies effectively like flat to low single-digit, fee-for-service growth. I know in the past you've talked about this segment growing in line with the market, call it high single digits.

Speaker #3: Our top line Medicare Advantage reimbursement is not a percent of total premium . It's not impacted by risk adjustment . In fact , you know , pressure on the top line for payers generally causes them to reach out more proactively when it comes to seeking opportunities to provide great care for their patients and good access .

Speaker #3: While also driving improvement in utilization . And so from that perspective , that actually helps our growth . So , you know , we tend to get lumped into some of those macro issues with payers , but just want to make it very clear that that is actually probably a good thing for DIY .

Matthew Shea: I know in the past you've talked about this segment growing in line with the market, call it high single digits. Maybe just help us unpack the assumptions in the fee-for-service revenue outlook.

Matthew Shea: Maybe just help us unpack the assumptions in the fee-for-service revenue outlook.

Rob Carter: Yeah. Hey, Matt, it's Rob. So I think the dynamic that you're seeing here is really about the sheer volume of capitated lives that are coming under management. With that, and especially in markets like Florida, there's going to be some minor cannibalization of fee-for-service volumes. That's a little bit of the impact that you see there. You know, beyond that, no, we do expect to continue to see organic growth from our own practice efforts. A lot of the growth that we saw in 2025 was driven by ramping new markets like Florida and Oregon. As Florida and Oregon continue to mature, some of that organic growth is going to erode slightly.

Robert Carter: Yeah. Hey, Matt, it's Rob. So I think the dynamic that you're seeing here is really about the sheer volume of capitated lives that are coming under management. With that, and especially in markets like Florida, there's going to be some minor cannibalization of fee-for-service volumes. That's a little bit of the impact that you see there.

Speaker #6: Okay . And then maybe just a quick follow up on that . You know , we get a lot of investor questions about this .

Speaker #6: Is just like the , the converse side of that , you know , demands higher . But what happens to margins ? And I know you just alluded to this about how pricing is effectively independent of rate cycles .

Speaker #6: But if the pie is shrinking , you know , there's a , there's a thesis out there that it does hit providers somewhere , maybe just speak to how you can protect contract terms in a potentially lower rate environment .

Robert Carter: You know, beyond that, no, we do expect to continue to see organic growth from our own practice efforts. A lot of the growth that we saw in 2025 was driven by ramping new markets like Florida and Oregon. As Florida and Oregon continue to mature, some of that organic growth is going to erode slightly. You know, the main area of focus continues to be the capitated revenue line as well as the attachment from pharmacy, and we're very excited about the growth there.

Speaker #6: So as we see that higher demand for your offerings , come on , that that we don't need to be concerned about any contract structures loosening or any contracts going underwater , if you will .

Speaker #6: Thanks .

Speaker #3: Yeah , absolutely . I think at this at this point in time , it's really important to keep in mind that we've got a very unique care model in terms of our combination of both employed and network providers in markets where we're taking population , population level , part B , capitation , that's both good for patients because it means better access because of our employed clinic model , higher level ancillary services in the community , but it also means we've got much stronger control over the practice patterns of the physicians .

Daniel Virnich: you know, the main area of focus continues to be the capitated revenue line as well as the attachment from pharmacy, and we're very excited about the growth there.

Matthew Shea: Okay. That's great color. Thanks, guys. I'll hop back in the queue.

Daniel Virnich: Thanks, Matt.

Operator: The next question is a follow-up from David Larsen with BTIG. Please proceed.

David Larsen: Can you talk a little bit about your expectations for SG&A in 2026? It looks like for the year, as a percentage of revenue, it improved by 642 basis points. Just any thoughts on how SG&A should trend in 2026 as a percentage of revenue? Should we see another significant improvement there?

Speaker #3: Since a good chunk of them are employed by us and we own the network . Of contracted providers , that means we're able to control care delivery and price contracts more competitively , we believe , than anybody else in the market at this point in time .

Speaker #3: So from that perspective, we are truly the best alternative for a payer, both from a pricing perspective as well as just a care delivery and coordination perspective.

Rob Carter: You will see improvements, not to that degree. As we talked about in the script, there is some investment going on for growth. The level of risk that we're taking at this point, you know, as measured by lives under management, which is represented by that significant percent growth in the capitated revenue line, requires some growth. But yes, you'll continue to see the scale there. That's something that Dan and I are keenly focused on and aware of, and you'll continue to see our discipline in that area.

Robert Carter: You will see improvements, not to that degree. As we talked about in the script, there is some investment going on for growth. The level of risk that we're taking at this point, you know, as measured by lives under management, which is represented by that significant percent growth in the capitated revenue line, requires some growth. But yes, you'll continue to see the scale there. That's something that Dan and I are keenly focused on and aware of, and you'll continue to see our discipline in that area.

Speaker #6: Okay . Appreciate it . Thank you .

Speaker #3: Thanks , Matt .

David Larsen: Free cash flow is expected to be positive in 2026?

Rob Carter: Exciting and second half of the year, yes.

Robert Carter: Exciting and second half of the year, yes.

David Larsen: Okay. The fee-for-service

Daniel Virnich: Dave, are you still there? I think we might have lost audio on Dave.

Operator: Okay, the next question comes from Yuan Zhi with B. Riley. Please proceed.

Yuan Zhi: Thanks for taking our question. For your $116 million revenue guidance with the capitated contract, can you talk about the underlying assumption there? Right now you are in 5 markets in Florida. Are you expanding further? How the delegated model there will contribute to this growth, meaningful growth in 2026.

Daniel Virnich: Yeah. As we commented on in the script, we've got about $50 million of run rate revenue coming from our Florida-based delegated contracts. You know, beyond that, we have a healthy pipeline within existing markets. The simple answer is no, we don't need to expand beyond the markets we're in to hit that number. We are opportunistic about growth. If the right opportunity comes for that expansion, then we'll obviously take a very serious look at that.

Robert Carter: Yeah. As we commented on in the script, we've got about $50 million of run rate revenue coming from our Florida-based delegated contracts. You know, beyond that, we have a healthy pipeline within existing markets. The simple answer is no, we don't need to expand beyond the markets we're in to hit that number. We are opportunistic about growth. If the right opportunity comes for that expansion, then we'll obviously take a very serious look at that.

Yuan Zhi: Yeah. Got it.

Operator: Once again, to ask a question, that's star one on your telephone keypad. The next question is a follow-up question from Matthew Shea with Needham & Company. Please proceed.

Matthew Shea: Hey, thanks for letting me back in. I wanted to maybe take a step back and just ask a bit of a higher level question. You know, with the Medicare Advantage rate notice for 2027, we effectively saw the whole value-based care sell off, you know, yourselves included, although to a lesser extent. Maybe just speak to TOI's positioning in a potentially lower rate environment. Obviously, payers have already been struggling with oncology trends, so I would expect demand would only accelerate in a time when margins are tighter. Would love to kinda get your thoughts on that topic.

Matthew Shea: Obviously, payers have already been struggling with oncology trends, so I would expect demand would only accelerate in a time when margins are tighter. Would love to kinda get your thoughts on that topic.

Daniel Virnich: Yeah, absolutely. Thanks, Matt. That's actually a very important question and something that we continue to try to drive clarity with our investors on, which is the MA rate cycle and sort of pressure that you've seen health plans and, you know, full risk medical groups that are getting a percent of premium base is actually a tailwind for TOI. Our top line Medicare Advantage reimbursement is not a percent of total premium. It's not impacted by risk adjustment. In fact, you know, pressure on the top line for payers generally causes them to reach out more proactively when it comes to seeking opportunities to provide great care for their patients and good access while also driving improvement in utilization. From that perspective, that actually helps our growth.

Daniel Virnich: Our top line Medicare Advantage reimbursement is not a percent of total premium. It's not impacted by risk adjustment. In fact, you know, pressure on the top line for payers generally causes them to reach out more proactively when it comes to seeking opportunities to provide great care for their patients and good access while also driving improvement in utilization. From that perspective, that actually helps our growth. You know, we tend to get lumped into some of those macro issues with payers, but just wanna make it very clear that that is actually probably a good thing for TOI.

Daniel Virnich: You know, we tend to get lumped into some of those macro issues with payers, but just wanna make it very clear that that is actually probably a good thing for TOI.

Matthew Shea: Okay. Maybe just a quick follow-up on that. You know, we get a lot of investor questions about this. It's just like the converse side to that, you know, demand's higher, but what happens to margins? I know you just alluded to this about how pricing is effectively independent of rate cycles, but if the pie is shrinking, you know, there's a thesis out there that it does hit providers somewhere. Maybe just speak to how you can protect contract terms in a potentially lower rate environment. As we see that higher demand for your offerings come on, that we don't need to be concerned about any contract structures loosening or any contracts going underwater, if you will. Thanks.

Matthew Shea: Maybe just speak to how you can protect contract terms in a potentially lower rate environment. As we see that higher demand for your offerings come on, that we don't need to be concerned about any contract structures loosening or any contracts going underwater, if you will. Thanks.

Daniel Virnich: Yeah, absolutely. I think at this point in time, it's really important to keep in mind that we've got a very unique care model in terms of our combination of both employed and network providers in markets where we're taking population level Part D capitation. That's both good for patients because it means better access because of our employed clinic model, higher level ancillary services in the community. It also means we've got much stronger control over the practice patterns of the physicians, since a good chunk of them are employed by us and we own the network of contracted providers. That means we're able to control care delivery and price contracts more competitively, we believe, than anybody else in the market at this point in time.

Daniel Virnich: It also means we've got much stronger control over the practice patterns of the physicians, since a good chunk of them are employed by us and we own the network of contracted providers. That means we're able to control care delivery and price contracts more competitively, we believe, than anybody else in the market at this point in time.From that perspective, we are truly the best alternative for a payer, both from a pricing perspective, as well as just a care delivery and coordination perspective.

Daniel Virnich: From that perspective, we are truly the best alternative for a payer, both from a pricing perspective, as well as just a care delivery and coordination perspective.

Matthew Shea: Okay, appreciate it. Thank you.

Daniel Virnich: Thanks, Matt.

Operator: Thank you. At this time, this does conclude today's teleconference. You may disconnect your lines at this time. Thank you for your participation and have a great day.

Q4 2025 The Oncology Institute Inc Earnings Call

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