In 2017, PhRMA commissioned a white paper studying the flow of dollars in the US pharmaceutical marketplace and how total spending on brand medicines at the point of sale is distributed across stakeholders that make up the US pharmaceutical supply chain. Since publication of that study, spending on prescription medicines in the US has continued to grow, and many of the market dynamics in place during the period of the original study (2013 through 2015) have persisted from 2016 through 2018. In this update to the original study, we seek to better understand which trends have continued, which new trends have emerged, and how the distribution of total point of sale brand medicine spending across the supply chain has evolved over the last three years.