10-Q

UNITED STATES

SECURITIES AND EXCHANGE COMMISSION

WASHINGTON, DC 20549

FORM 10-Q

(Mark One)

☒ QUARTERLY REPORT PURSUANT TO SECTION 13 OR 15(d) OF THE SECURITIES EXCHANGE ACT OF 1934

For the quarterly period ended June 30, 2022.

OR

☐ TRANSITION REPORT PURSUANT TO SECTION 13 OR 15(d) OF THE SECURITIES EXCHANGE ACT OF 1934

For the transition period from                      to                     .

Commission file number 001-33528

OPKO Health, Inc.

(Exact Name of Registrant as Specified in Its Charter)

Delaware	75-2402409
(State or Other Jurisdiction of Incorporation or Organization)	(I.R.S. Employer Identification No.)

4400 Biscayne Blvd.
Miami	FL	33137
(Address of Principal Executive Offices) (Zip Code)
(305)	575-4100
(Registrant’s Telephone Number, Including Area Code)

Securities registered pursuant to Section 12(b) of the Act:

Title of each class	Trading Symbol	Name of each exchange on which registered
Common Stock, par value $0.01 per share	OPK	NASDAQ Global Select Market

Indicate by check mark whether the registrant: (1) has filed all reports required to be filed by Section 13 or 15(d) of the Securities Exchange Act of 1934 during the preceding 12 months (or for such shorter period that the registrant was required to file such reports), and (2) has been subject to such filing requirements for the past 90 days.    ý  Yes    ¨  NO

Indicate by check mark whether the registrant has submitted electronically every Interactive Data File required to be submitted pursuant to Rule 405 of Regulation S-T during the preceding 12 months (or for such shorter period that the registrant was required to submit such files).    ý  Yes    ¨  NO

Indicate by check mark whether the registrant is a large accelerated filer, an accelerated filer, a non-accelerated filer, smaller reporting company, or an emerging growth company. See the definitions of “large accelerated filer,” “accelerated filer,” “smaller reporting company,” and “emerging growth company” in Rule 12b-2 of the Exchange Act:

Large accelerated filer	x	Accelerated filer	☐
Non-accelerated filer	¨	Smaller reporting company	☐
		Emerging growth company	☐

If an emerging growth company, indicate by check mark if the registrant has elected not to use the extended transition period for complying with any new or revised financial accounting standards provided pursuant to Section 13(a) of the Exchange Act. ¨

Indicate by check mark whether the registrant is a shell company (as defined in Rule 12b-2 of the Exchange Act):   ☐  YES    ý  NO

As of July 28, 2022, the registrant had 771,959,579 shares of Common Stock outstanding.

TABLE OF CONTENTS

PART I. FINANCIAL INFORMATION		Page
Item 1.	Financial Statements
Condensed Consolidated Balance Sheets as of June 30, 2022, and December 31, 2021 (unaudited)		7
Condensed Consolidated Statements of Operations for the three and six months ended June 30, 2022, and 2021 (unaudited)		8
Condensed Consolidated Statements of Comprehensive Income (Loss) for the three and six months ended June 30, 2022, and 2021 (unaudited)		9
Condensed Consolidated Statements of Equity for the three and six months ended June 30, 2022, and 2021 (unaudited)		10
Condensed Consolidated Statements of Cash Flows for the six months ended June 30, 2022, and 2021 (unaudited)		12
Notes to Condensed Consolidated Financial Statements (unaudited)		13
Item 2.	Management’s Discussion and Analysis of Financial Condition and Results of Operations	48
Item 3.	Quantitative and Qualitative Disclosures About Market Risk	64
Item 4.	Controls and Procedures	65
PART II. OTHER INFORMATION
Item 1.	Legal Proceedings	66
Item 1A.	Risk Factors	67
Item 2.	Unregistered Sales of Equity Securities and Use of Proceeds	67
Item 3.	Defaults Upon Senior Securities	67
Item 4.	Mine Safety Disclosures	67
Item 5.	Other Information	67
Item 6.	Exhibits	68
Signatures		69

3

CAUTIONARY STATEMENT REGARDING FORWARD-LOOKING STATEMENTS

This Quarterly Report on Form 10-Q contains “forward-looking statements,” as that term is defined under the Private Securities Litigation Reform Act of 1995 (“PSLRA”), Section 27A of the Securities Act of 1933, as amended (the “Securities Act”), and Section 21E of the Securities Exchange Act of 1934, as amended (the “Exchange Act”). Forward-looking statements include statements about our expectations, beliefs or intentions regarding our product development efforts, business, financial condition, results of operations, strategies or prospects, including the potential impact of the COVID-19 pandemic on our businesses, operating results, cash flows and/or financial condition. You can identify forward-looking statements by the fact that these statements do not relate strictly to historical or current matters. Rather, forward-looking statements relate to anticipated or expected events, activities, trends or results as of the date they are made. Because forward-looking statements relate to matters that have not yet occurred, these statements are inherently subject to risks and uncertainties that could cause our actual results to differ materially from any future results expressed or implied by the forward-looking statements. Many factors could cause our actual activities or results to differ materially from the activities and results anticipated in forward-looking statements. These factors include those described below and in “Item 1A-Risk Factors” of our Annual Report on Form 10-K for the year ended December 31, 2021, and described from time to time in our other filings with the Securities and Exchange Commission (the “SEC”). We do not undertake any obligation to update forward-looking statements, except to the extent required by applicable law. We intend that all forward-looking statements be subject to the safe-harbor provisions of the PSLRA. These forward-looking statements are only predictions and reflect our views as of the date they are made with respect to future events and financial performance.

Risks and uncertainties, the occurrence of which could adversely affect our business, include the following:

•our business may be materially adversely affected by the coronavirus (COVID-19) pandemic, including the impact from potential declines in testing needs as infection rates decline;

•we have had a history of losses and may not generate sustained positive cash flow sufficient to fund our operations and research and development programs;

•our need for, and ability to obtain, additional financing when needed on favorable terms, or at all;

•adverse results in material litigation matters or governmental inquiries;

•the risks inherent in developing, obtaining regulatory approvals for and commercializing new, commercially viable and competitive products and treatments;

•our research and development activities may not result in commercially viable products;

•that earlier clinical results of effectiveness and safety may not be reproducible or indicative of future results;

•that we may fail to obtain regulatory approval for Somatrogon (hGH-CTP) in the United States (“U.S.”) and other territories in which we have applied, or successfully commercialize hGH-CTP Somatrogon (hGH-CTP);

•that we may not generate or sustain profits or cash flow from our laboratory operations or substantial revenue from Rayaldee and our other pharmaceutical and diagnostic products;

•that currently available over-the-counter and prescription products, as well as products under development by others, may prove to be as or more effective than our products for the indications being studied;

•our ability and our distribution and marketing partners’ ability to comply with regulatory requirements regarding the sales, marketing and manufacturing of our products and product candidates and the operation of our laboratories;

•the performance of our third-party distribution partners, licensees and manufacturers over which we have limited control;

•changes in regulation and policies in the U.S. and other countries, including increasing downward pressure on healthcare reimbursement;

•our ability to manage our growth and our expanded operations;

•increased competition, including price competition;

•changing relationships with payors, including the various state and multi-state programs, suppliers and strategic partners;

•efforts by third-party payors to reduce utilization and reimbursement for clinical testing services;

4

•our ability to maintain reimbursement coverage for our products and services, including Rayaldee and the 4Kscore test;

•failure to timely or accurately bill and collect for our services;

•the information technology systems that we rely on may be subject to unauthorized tampering, cyberattack or other data security or privacy incidents that could impact our billing processes or disrupt our operations;

•failure to obtain and retain new clients and business partners, or a reduction in tests ordered or specimens submitted by existing clients;

•failure to establish, and perform to, appropriate quality standards to assure that the highest level of quality is observed in the performance of our testing services;

•failure to maintain the security of patient-related information;

•our ability to obtain and maintain intellectual property protection for our products;

•our ability to defend our intellectual property rights with respect to our products;

•our ability to operate our business without infringing the intellectual property rights of others;

•our ability to attract and retain key scientific and management personnel;

•the risk that the carrying value of certain assets may exceed the fair value of the assets causing us to impair goodwill or other intangible assets;

•our ability to comply with the terms of our Corporate Integrity Agreement with the Office of Inspector General of the Department of Health and Human Services;

•failure to obtain and maintain regulatory approval outside the U.S.; and

•legal, economic, political, regulatory, currency exchange, and other risks associated with international operations.

5

PART I. FINANCIAL INFORMATION

Unless the context otherwise requires, all references in this Quarterly Report on Form 10-Q to the “Company”, “OPKO”, “we”, “our”, “ours”, and “us” refer to OPKO Health, Inc., a Delaware corporation, including our consolidated subsidiaries.

Item 1. Financial Statements

The accompanying unaudited Notes to Condensed Consolidated Financial Statements are an integral part of these statements.

6

OPKO Health, Inc. and Subsidiaries

CONDENSED CONSOLIDATED BALANCE SHEETS

(Unaudited)

(In thousands, except share and per share data)

	June 30, 2022		December 31, 2021
ASSETS
Current assets:
Cash and cash equivalents	$	210,458	$	134,710
Accounts receivable, net	158,425		259,637
Inventory, net	83,306		86,502
Other current assets and prepaid expenses	42,563		27,170
Assets held for sale	—		314,994
Total current assets	494,752		823,013
Property, plant and equipment, net	78,601		79,727
Intangible assets, net	862,409		321,683
In-process research and development	195,000		590,200
Goodwill	578,845		520,601
Investments	108,685		10,729
Operating lease right-of-use assets	42,412		44,228
Other assets	8,898		9,534
Total assets	$	2,369,602	$	2,399,715
LIABILITIES AND EQUITY
Current liabilities:
Accounts payable	$	56,107	$	82,040
Accrued expenses	128,254		193,493
Current maturities of operating leases	12,122		11,624
Liabilities associated with assets held-for-sale	—		28,156
Current portion of lines of credit and notes payable	18,989		14,695
Total current liabilities	215,472		330,008
Operating lease liabilities	30,876		33,097
Convertible notes	211,477		187,935
Deferred tax liabilities	176,741		148,487
Other long-term liabilities, principally contract liabilities, contingent consideration and lines of credit	16,237		15,062
Total long-term liabilities	435,331		384,581
Total liabilities	650,803		714,589
Equity:
Common Stock - $0.01 par value, 1,000,000,000 shares authorized; 780,591,681 and 690,082,283 shares issued at June 30, 2022 and December 31, 2021, respectively	7,806		6,901
Treasury Stock - 8,655,082 shares at June 30, 2022 and December 31, 2021, respectively	(1,791)		(1,791)
Additional paid-in capital	3,413,556		3,222,487
Accumulated other comprehensive loss	(49,171)		(30,495)
Accumulated deficit	(1,651,601)		(1,511,976)
Total shareholders’ equity	1,718,799		1,685,126
Total liabilities and equity	$	2,369,602	$	2,399,715

The accompanying unaudited Notes to Condensed Consolidated Financial Statements are an integral part of these statements.

7

OPKO Health, Inc. and Subsidiaries

CONDENSED CONSOLIDATED STATEMENTS OF OPERATIONS

(Unaudited)

(In thousands, except share and per share data)

	For the three months ended June 30,				For the six months ended June 30,
	2022		2021		2022		2021
Revenues:
Revenue from services	$	186,804	$	397,197	$	473,402	$	904,149
Revenue from products	35,892		35,663		72,550		69,608
Revenue from transfer of intellectual property and other	87,197		9,548		93,159		13,816
Total revenues	309,893		442,408		639,111		987,573
Costs and expenses:
Cost of service revenue	171,836		267,807		393,039		607,235
Cost of product revenue	22,475		25,101		45,147		49,179
Selling, general and administrative	101,464		113,236		219,000		225,522
Research and development	17,254		18,222		35,566		37,537
Contingent consideration	175		(103)		69		(1,059)
Amortization of intangible assets	22,793		12,574		44,818		25,151
Gain on sale of assets	(15,365)		—		(15,365)		—
Total costs and expenses	320,632		436,837		722,275		943,565
Operating income (loss)	(10,739)		5,571		(83,164)		44,008
Other income and (expense), net:
Interest income	161		6		171		12
Interest expense	(3,075)		(4,887)		(5,737)		(10,282)
Fair value changes of derivative instruments, net	338		(272)		206		(711)
Other expense, net	(72,997)		(11,783)		(74,439)		(12,711)
Other expense, net	(75,572)		(16,936)		(79,799)		(23,692)
Income (loss) before income taxes and investment losses	(86,312)		(11,365)		(162,963)		20,316
Income tax benefit (provision)	(15,070)		(4,754)		6,196		(5,314)
Net income (loss) before investment losses	(101,382)		(16,119)		(156,766)		15,002
Loss from investments in investees	(268)		(67)		(316)		(110)
Net income (loss)	$	(101,650)	$	(16,186)	$	(157,083)	$	14,892
Income (loss) per share, basic and diluted:
Income (loss) per share	$	(0.14)	$	(0.03)	$	(0.23)	$	0.02
Weighted average common shares outstanding, basic and diluted	712,548,661		646,996,891		686,597,899		644,001,280

The accompanying unaudited Notes to Condensed Consolidated Financial Statements are an integral part of these statements.

8

OPKO Health, Inc. and Subsidiaries

CONDENSED CONSOLIDATED STATEMENTS OF COMPREHENSIVE INCOME (LOSS)

(Unaudited)

(In thousands)

	For the three months ended June 30,				For the six months ended June 30,
	2022		2021		2022		2021
Net income (loss)	$	(101,650)	$	(16,186)	$	(157,083)	$	14,892
Other comprehensive loss, net of tax:
Change in foreign currency translation and other comprehensive loss	(17,756)		(9,070)		(18,676)		(9,070)
Comprehensive income (loss)	$	(119,406)	$	(25,256)	$	(175,759)	$	5,822

The accompanying unaudited Notes to Condensed Consolidated Financial Statements are an integral part of these statements.

9

CONSOLIDATED STATEMENTS OF EQUITY

(Unaudited)

(In thousands, except share data)

For the three and six months ended June 30, 2022

	Common Stock			Treasury			Additional Paid-In Capital		Accumulated Other Comprehensive Loss		Accumulated Deficit		Total
	Shares	Dollars		Shares	Dollars
Balance at March 31, 2022	690,138,033	$	6,901	(8,655,082)	$	(1,791)	$	3,191,139	$	(31,415)	$	(1,549,951)	$	1,614,884
Equity-based compensation expense	—	—		—	—		4,308		—		—		4,308
Exercise of common stock options and warrants	546,337	6		—	—		(366)		—		—		(360)
ModeX Acquisition	89,907,311	899		—	—		218,475		—		—		219,374
Net loss	—	—		—	—		—		—		(101,650)		(101,650)
Other comprehensive loss	—	—		—	—		—		(17,756)		—		(17,756)
Balance at June 30, 2022	780,591,681	$	7,806	(8,655,082)	$	(1,791)	$	3,413,556	$	(49,171)	$	(1,651,601)	$	1,718,799

	Common Stock			Treasury			Additional Paid-In Capital		Accumulated Other Comprehensive Loss		Accumulated Deficit		Total
	Shares	Dollars		Shares	Dollars
Balance at December 31, 2021	690,082,283	$	6,901	(8,655,082)	$	(1,791)	$	3,222,487	$	(30,495)	$	(1,511,976)	$	1,685,126
Equity-based compensation expense	—	—		—	—		11,925		—		—		11,925
Exercise of common stock options and warrants	602,087	6		—	—		(231)		—		—		(225)
Adoption of ASU 2020-06	—	—		—	—		(39,100)		—		17,458		(21,642)
ModeX Acquisition	89,907,311	899		—	—		218,475		—		—		219,374
Net loss	—	—		—	—		—		—		(157,083)		(157,083)
Other comprehensive loss	—	—		—	—		—		(18,676)		—		(18,676)
Balance at June 30, 2022	780,591,681	$	7,806	(8,655,082)	$	(1,791)	$	3,413,556	$	(49,171)	$	(1,651,601)	$	1,718,799

The accompanying unaudited Notes to Condensed Consolidated Financial Statements are an integral part of these statements.

10

CONSOLIDATED STATEMENTS OF EQUITY

(Unaudited)

(In thousands, except share data)

For the three and six months ended June 30, 2021

	Common Stock			Treasury			Additional Paid-In Capital		Accumulated Other Comprehensive Income (loss)		Accumulated Deficit		Total
	Shares	Dollars		Shares	Dollars
Balance at March 31, 2021	670,703,076	$	6,707	(549,907)	$	(1,791)	$	3,155,648	$	(13,295)	$	(1,450,755)	$	1,696,514
Equity-based compensation expense	—	—		—	—		3,460		—		—		3,460
Exercise of common stock options and warrants	63,625	1		—	—		158		—		—		159
2025 convertible notes	19,051,270	190		(8,105,175)	—		55,085		—		—		55,275
Net loss	—	—		—	—		—		—		(16,186)		(16,186)
Other comprehensive income	—	—		—	—		—		3,363		—		3,363
Balance at June 30, 2021	689,817,971	$	6,898	(8,655,082)	$	(1,791)	$	3,214,351	$	(9,932)	$	(1,466,941)	$	1,742,585

	Common Stock			Treasury			Additional Paid-In Capital		Accumulated Other Comprehensive Income (loss)		Accumulated Deficit		Total
	Shares	Dollars		Shares	Dollars
Balance at December 31, 2020	670,585,576	$	6,706	(549,907)	$	(1,791)	$	3,152,694	$	(4,225)	$	(1,481,833)	$	1,671,551
Equity-based compensation expense	—	—		—	—		6,107		—		—		6,107
Exercise of common stock options and warrants	181,125	2		—	—		465		—		—		467
2025 convertible notes	19,051,270	190		(8,105,175)	—		55,085		—		—		55,275
Net income	—	—		—	—		—		—		14,892		14,892
Other comprehensive loss	—	—		—	—		—		(5,707)		—		(5,707)
Balance at June 30, 2021	689,817,971	$	6,898	(8,655,082)	$	(1,791)	$	3,214,351	$	(9,932)	$	(1,466,941)	$	1,742,585

The accompanying unaudited Notes to Condensed Consolidated Financial Statements are an integral part of these statements.

11

OPKO Health, Inc. and Subsidiaries

CONDENSED CONSOLIDATED STATEMENTS OF CASH FLOWS

(Unaudited)

(In thousands)

	For the six months ended June 30,
	2022		2021
Cash flows from operating activities:
Net income (loss)	$	(157,083)	$	14,892
Adjustments to reconcile net income (loss) to net cash (used in) provided by operating activities:
Depreciation and amortization	55,809		40,561
Non-cash interest	1,364		4,981
Amortization of deferred financing costs	569		424
Losses from investments in investees	316		110
Equity-based compensation – employees and non-employees	11,925		6,107
Realized loss (gain) on disposal of fixed assets and sales of equity securities	(477)		(3,146)
Loss on conversion of the 2025 Notes	—		11,111
Change in fair value of equity securities and derivative instruments	73,724		873
Change in fair value of contingent consideration	69		(1,059)
Gain on sale of GeneDx	(15,365)		—
Deferred income tax benefit	(8,942)		2,479
Changes in assets and liabilities:
Accounts receivable, net	95,864		20,352
Inventory, net	2,864		(3,817)
Other current assets and prepaid expenses	(6,502)		(13,904)
Other assets	(260)		1,388
Accounts payable	(19,508)		(11,651)
Foreign currency measurement	4,295		(2,532)
Contract liabilities	(17)		(7,425)
Accrued expenses and other liabilities	(69,978)		(49,159)
Net cash (used in) provided by operating activities	(31,333)		10,585
Cash flows from investing activities:
Proceeds from sale of investments	—		8,079
Proceeds from sale of GeneDx	115,423		—
Acquisition of businesses, net of cash	(2,071)		—
Proceeds from the sale of property, plant and equipment	870		165
Capital expenditures	(10,630)		(18,192)
Net cash provided by (used in) investing activities	103,592		(9,948)
Cash flows from financing activities:
Issuance of common stock	1		—
Proceeds from the exercise of common stock options	(225)		465
Borrowings on lines of credit	684,467		982,797
Repayments of lines of credit	(679,860)		(990,190)
Net cash provided by (used in) financing activities	4,383		(6,928)
Effect of exchange rate changes on cash and cash equivalents	(894)		(163)
Net increase (decrease) in cash and cash equivalents	75,748		(6,454)
Cash and cash equivalents at beginning of period	134,710		72,211
Cash and cash equivalents at end of period	$	210,458	$	65,757
SUPPLEMENTAL INFORMATION:
Interest paid	$	3,554	$	4,883
Income taxes paid, net of refunds	$	4,647	$	3,690
Non-cash financing:
Shares issued upon the conversion of:
2025 Convertible Notes	$	—	$	68,775
Common stock options and warrants, surrendered in net exercise	$	655	$	—
Issuance of common stock for acquisition of ModeX	$	219,374	$	—
Fair value of shares included in consideration from Sema4	$	172,000	$	—

The accompanying unaudited Notes to Condensed Consolidated Financial Statements are an integral part of these statements.

12

OPKO Health, Inc. and Subsidiaries

NOTES TO CONDENSED CONSOLIDATED FINANCIAL STATEMENTS (unaudited)

NOTE 1 BUSINESS AND ORGANIZATION

We are a diversified healthcare company that seeks to establish industry-leading positions in large and rapidly growing medical markets. Our diagnostics business includes BioReference Health, LLC, formerly known as BioReference Laboratories, Inc. (“BioReference”), one of the nation’s largest full service laboratories with an almost 250-person sales and marketing team to drive growth and leverage new products. Our pharmaceutical business features Rayaldee, a U.S. Food and Drug Administration (“FDA”) approved treatment for secondary hyperparathyroidism (“SHPT”) in adults with stage 3 or 4 chronic kidney disease (“CKD”) and vitamin D insufficiency and a pipeline of products in various stages of development. Our leading product in development is Somatrogon (hGH-CTP), a once-weekly human growth hormone for which we have partnered with Pfizer, Inc. (“Pfizer”) and successfully completed a phase 3 study in August 2019. Regulatory applications for Somatrogon (hGH-CTP) have been submitted to the applicable regulatory bodies for review in several countries around the world. In February 2022, the European Commission granted marketing authorization in the European Union for Somatrogon (hGH-CTP) under the brand name NGENLA® to treat children and adolescents from as young as three years of age with growth disturbance due to insufficient secretion of growth hormone, and we recently received pricing approval in Germany. In January 2022, the Ministry of Health, Labour and Welfare in Japan approved NGENLA® (Somatrogon) for the long-term treatment of pediatric patients who have growth failure due to an inadequate secretion of endogenous growth hormone and we recently received pricing approval. In October 2021, Health Canada approved NGENLA® for the long-term treatment of pediatric patients who have growth hormone deficiency, and Australia’s Therapeutic Goods Administration approved NGENLA® for the long-term treatment of pediatric patients with growth disturbance due to insufficient secretion of growth hormone. Pfizer submitted the initial Biologics License Application (“BLA”) with the FDA for approval of Somatrogon (hGH-CTP) in the United States and received a Complete Response Letter in January 2022. Pfizer and OPKO are evaluating the FDA’s comments and will work with the agency to determine the best path forward for Somatrogon (hGH-CTP) in the United States. We are incorporated in Delaware, and our principal executive offices are located in leased offices in Miami, Florida.

Through BioReference, we provide laboratory testing services, primarily to customers in the larger metropolitan areas in New York, New Jersey, Florida, Texas, Maryland, California, Pennsylvania, Delaware, Washington, DC, Illinois and Massachusetts, as well as to customers in a number of other states. We offer a comprehensive test menu of clinical diagnostics for blood, urine and tissue analysis. This includes hematology, clinical chemistry, immunoassay, infectious diseases, serology, hormones, and toxicology assays, as well as Pap smear, anatomic pathology (biopsies) and other types of tissue analysis. We market our laboratory testing services directly to physicians, geneticists, hospitals, clinics, correctional and other health facilities.

We operate established pharmaceutical platforms in Ireland, Chile, Spain, and Mexico, which are generating revenue and from which we expect to generate positive cash flow and facilitate future market entry for our products currently in development. In addition, we have a development and commercial supply pharmaceutical company and a global supply chain operation and holding company in Ireland. We own a specialty active pharmaceutical ingredients (“APIs”) manufacturer in Israel, which we expect will facilitate the development of our pipeline of molecules and compounds for our proprietary molecular diagnostic and therapeutic products.

Our research and development activities are primarily performed at facilities in Woburn, MA, Waterford, Ireland, Kiryat Gat, Israel, and Barcelona, Spain.

On May 9, 2022 (the “Closing Date”), the Company entered into an Agreement and Plan of Merger (the “ModeX Merger Agreement”) with Orca Acquisition Sub, Inc., a Delaware corporation and wholly owned subsidiary of the Company (“Merger Sub”), ModeX Therapeutics, Inc., a Delaware corporation (“ModeX”) and Gary J. Nabel, solely in his capacity as sellers’ representative, pursuant to which Merger Sub merged with and into ModeX (the “ModeX Merger”), with ModeX surviving the ModeX Merger as a wholly owned subsidiary of the Company. The Company paid the entirety of the $300.0 million purchase price pursuant to the issuance of an aggregate of 89,907,310 shares (the “Consideration Shares”) of the Company’s common stock, par value $0.01 per share (“Common Stock”), to the former stockholders of ModeX (the “Selling Stockholders”), of which 10% of such shares were deposited in a twelve-month escrow for purposes of satisfying the potential indemnity obligations of the Selling Stockholders under the ModeX Merger Agreement. Additionally, the Company issued equity awards to ModeX employees in an amount equal to $12.4 million, which was deducted from the consideration payable on the Closing Date. If any of such awards are forfeited or otherwise remain unvested on the four-year anniversary of the Closing Date, up to $2.6 million shares of Common Stock (valued at the same price used for determining the number of Consideration Shares issuable upon consummation of the ModeX Merger) may be distributed pro rata to ModeX’s former stockholders in respect of such forfeited or unvested awards. Shares of Common Stock with respect to such potential distribution have been escrowed and will remain escrowed for such four-year period. For accounting purposes, the shares were valued at $219.4 million, based on

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the closing price per share of our Common Stock of $2.44 as reported by NASDAQ Global Select Market (“NASDAQ”) on the Closing Date.

In connection with the ModeX Merger, the Company appointed Elias A. Zerhouni, M.D., Gary J. Nabel, M.D., PhD., and Alexis Borisy to the Board of Directors of the Company (the “Board”), with Dr. Zerhouni serving as Vice Chair. Elizabeth Nabel, one of the founders of ModeX, was appointed as the Company’s new Chief Medical Officer. Dr. Gary J. Nabel has been named the Chief Executive Officer of ModeX and Chief Innovation Officer of the Company and Dr. Elias A.Zerhouni has been named the President of the Company.

In accordance with the ModeX Merger Agreement, Dr. Phillip Frost, the Company’s Chief Executive Officer and Chairman of the Board, Dr. Jane Hsiao, the Company’s Chief Technical Officer and a Director, and Frost Gamma Investments Trust (“FGIT”), a trust controlled by Dr. Frost, entered into a lockup and voting agreement, together with the Company (the “ModeX Lockup and Voting Agreement”), pursuant to which: (i) FGIT has agreed that, for a period of four years immediately following the Closing Date, it will not sell or otherwise transfer its shares of Common Stock, subject to certain customary exceptions; and (ii) Drs. Frost and Hsiao agreed that, for as long as Dr. Elias A. Zerhouni or Dr. Gary J. Nabel remains an employee of the Company or ModeX, Drs. Frost and Hsiao will vote, or cause to be voted, all of their respective shares of Common Stock in favor of such person’s election to the Board. Additionally, in accordance with the ModeX Merger Agreement, certain recipients of the Consideration Shares, holding in aggregate approximately 88.0% of the Consideration Shares, agreed not to sell or otherwise transfer their respective Consideration Shares for a period of four years immediately following the Closing Date on the same terms as contained in the ModeX Lockup and Voting Agreement.

On January 14, 2022, the Company entered into an Agreement and Plan of Merger and Reorganization (the “GeneDx Merger Agreement”) with Sema4 Holdings Corp., a Delaware corporation (“Sema4”), pursuant to which Sema4 acquired the Company’s former subsidiary, GeneDx LLC, (f/k/a GeneDx, Inc. “GeneDx”), (the “GeneDx Transaction”) in a transaction that closed on April 29, 2022 (the “GeneDx Closing”).

Upon the GeneDx Closing, Sema4 paid to the Company aggregate consideration of $150 million in cash (before deduction of transaction expenses and other customary purchase price adjustments), together with 80.0 million shares (the “Closing Shares”) of Sema4’s Class A common stock, par value $0.0001 per share (“Sema4 Common Stock”). Additionally, Sema4 has agreed to pay the Company up to an additional $150 million, which may be paid in Sema4 Common Stock, cash or a combination thereof in Sema4’s discretion, subject to GeneDx achieving certain revenue targets for the fiscal years ending December 31, 2022 and 2023 (the “Milestone Consideration”). Based on the closing price of Sema4 Common Stock on April 29, 2022, the total upfront consideration was approximately $322 million, and the total aggregate consideration, including the potential Milestone Consideration, was approximately $447 million. We recognized a gain of $15.4 million on the sale of GeneDx during the second quarter of 2022.

In connection with the transactions contemplated by the GeneDx Merger Agreement, on January 14, 2022, the Company entered into a Shareholder Agreement (the “Sema4 Shareholder Agreement”) with Sema4, pursuant to which the Company has agreed to, among other things, be subject to a lock-up period with respect to its shares of Sema4 Common Stock, which expires on April 29, 2024 with respect to the Closing Shares, and, if earned and received, would extend for periods of one-year and six-months following the issuance of shares, cash or a combination thereof, in respect of the first and second potential Milestone Consideration payments, respectively.

Pursuant to the GeneDx Merger Agreement, the Company designated, and Sema4 nominated for election an individual to serve on the board of directors of Sema4, and such nominee was elected by Sema4’s stockholders to serve as a director until Sema4’s 2024 annual meeting of stockholders. In addition, the Company has further agreed to certain standstill provisions whereby, subject to certain exceptions, it is obligated to refrain from taking certain actions with respect to the Sema4 Common Stock. The Company has also agreed to vote its shares of Sema4 Common Stock in accordance with the recommendations of Sema4’s board of directors for so long as it continues to hold at least 5% of the outstanding shares of Sema4 Common Stock. Further, Sema4 has also granted the Company certain customary shelf, piggyback and demand registration rights that require Sema4 to register the Company’s Sema4 Lock-Up Shares for resale under the Securities Act. OPKO’s intention is that we will no longer have a designee serving on Sema4’s board of directors upon the expiration of the Sema4 Lock-Up Period. As such, OPKO is not actively participating in the policy-making process of Sema4.

As of December 31, 2021, GeneDx met the held-for-sale accounting criteria and, its related assets and liabilities are classified as held for sale in the consolidated balance sheet. GeneDx was included in our diagnostics segment as of December 31, 2021.

NOTE 2 IMPACT OF COVID-19

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We continue to be a part of the coordinated public and private sector response to SARS-CoV-2, a novel strain of coronavirus, referred to as COVID-19. There continues to be a high level of uncertainty relating to how the pandemic will evolve, how governments and consumers will react, progress on the distribution of vaccines and whether the pandemic will have a longer-term effect on the healthcare industry and patient habits. BioReference is providing COVID-19 solutions, including diagnostic molecular testing and serology antibody testing, to meet the testing needs of its customers, including physicians, health systems, long-term care facilities, governments, schools, employers, professional sports teams and entertainment venues, as well as the general public through relationships with retail pharmacy chains.

Since the pandemic began in the U.S., we have invested in testing capabilities and infrastructure to meet demand for our molecular and antibody testing for COVID-19. Throughout the pandemic, we have managed our company-wide lab operations specimen acquisition, logistics, procurement, customer service, and initiatives to manage our cost structure to match the ever changing COVID-19 testing volumes and to manage efficiency gains in our core clinical lines of business. We anticipate that COVID-19 will continue to impact our business in 2022 and, overall, we expect COVID-19 test demand to continue to decline in 2022 as compared to 2021.

Revenue from services for the six months ended June 30, 2022 decreased by $430.7 million as compared to 2021 due to lower COVID-19 testing volumes. Excluding COVID-19 test volumes, for the six months ended June 30, 2022, routine clinical test volume decreased 26.2% as compared to volumes for the six months ended June 30, 2021.

In March 2022, the U.S. Health Resources and Services Administration ("HRSA") informed providers that, after March 22, 2022, it would stop accepting claims for testing and treatment for uninsured individuals under the HRSA COVID-19 Uninsured Program and that claims submitted prior to that date would be subject to eligibility and availability of funds. For the six months ended June 30, 2022, revenue for testing of uninsured individuals under the HRSA COVID-19 Uninsured Program represented approximately 5.7% of our COVID-19 testing revenue. As of June 30, 2022, less than 2% of our net accounts receivable was associated with claims for reimbursement for COVID-19 testing of uninsured individuals. Although we believe that our estimates for contractual allowances and patient price concessions are appropriate, actual results could differ from those estimates.

NOTE 3 SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES

Basis of presentation. The accompanying unaudited Condensed Consolidated Financial Statements have been prepared in accordance with accounting principles generally accepted in the U.S. (“GAAP”) and with the instructions to Form 10-Q and Article 10 of Regulation S-X. Accordingly, they do not include all information and notes required by GAAP for complete financial statements. In the opinion of management, all adjustments (consisting of only normal recurring adjustments or adjustments otherwise disclosed herein) considered necessary to present fairly the Company’s results of operations, financial position and cash flows have been made. The results of operations and cash flows for the six months ended June 30, 2022 are not necessarily indicative of the results of operations and cash flows that may be reported for the remainder of 2022 or any other future periods. The unaudited Condensed Consolidated Financial Statements should be read in conjunction with the audited Consolidated Financial Statements and the Notes to Consolidated Financial Statements included in our Annual Report on Form 10-K for the year ended December 31, 2021.

Principles of consolidation. The accompanying unaudited Condensed Consolidated Financial Statements include the accounts of OPKO Health, Inc. and our wholly-owned subsidiaries. All intercompany accounts and transactions are eliminated in consolidation.

Use of estimates. The preparation of financial statements in conformity with GAAP requires management to make estimates and assumptions that affect the reported amounts of assets and liabilities and disclosure of contingent assets and liabilities at the date of the financial statements and the reported amounts of revenues and expenses during the reporting period. Actual results could differ significantly from these estimates.

Cash and cash equivalents. Cash and cash equivalents include short-term, interest-bearing instruments with original maturities of 90 days or less at the date of purchase. We also consider all highly liquid investments with original maturities at the date of purchase of 90 days or less as cash equivalents. These investments include money markets, bank deposits, certificates of deposit and U.S. treasury securities.

Inventories. Inventories are valued at the lower of cost and net realizable value. Cost is determined by the first-in, first-out method. We consider such factors as the amount of inventory on hand, estimated time required to sell such inventories, remaining shelf-life, and current market conditions to determine whether inventories are stated at the lower of cost and net realizable value. Inventories at our diagnostics segment consist primarily of purchased laboratory supplies, which are used in our testing laboratories. Inventory obsolescence expense for the three and six months ended June 30, 2022 was $0.3 million and $1.0 million, respectively. Inventory obsolescence expense for the three and six months ended June 30, 2021 was $0.9 million and $3.9 million, respectively.

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Goodwill and intangible assets. Goodwill represents the difference between the purchase price and the estimated fair value of the net assets acquired accounted for by the acquisition method of accounting. Refer to Note 5. Goodwill, in-process research and development (“IPR&D”) and other intangible assets acquired in business combinations, licensing and other transactions was $1.6 billion and $1.4 billion, respectively, at June 30, 2022 and December 31, 2021.

Assets acquired and liabilities assumed in business combinations, licensing and other transactions are generally recognized at the date of acquisition at their respective fair values. Any excess of the purchase price over the estimated fair values of the net assets acquired is recognized as goodwill. At acquisition, we generally determine the fair value of intangible assets, including IPR&D, using the “income method.”

Subsequent to their acquisition, goodwill and indefinite lived intangible assets are tested at least annually as of October 1 for impairment, or when events or changes in circumstances indicate it is more likely than not that the carrying amount of such assets may not be recoverable.

Estimating the fair value of a reporting unit for goodwill impairment is highly sensitive to changes in projections and assumptions and changes in assumptions could potentially lead to impairment. We perform sensitivity analyses around our assumptions in order to assess the reasonableness of the assumptions and the results of our testing. Ultimately, potential changes in these assumptions may impact the estimated fair value of a reporting unit and result in an impairment if the fair value of such reporting unit is less than its carrying value. Goodwill was $578.8 million and $520.6 million, respectively, at June 30, 2022 and December 31, 2021. At December 31, 2021, Assets held for sale include $151.8 million of goodwill related to GeneDx.

Net intangible assets other than goodwill was $1,057.4 million and $911.9 million, including IPR&D of $195.0 million and $590.2 million at June 30, 2022 and December 31, 2021, respectively. Intangible assets are highly vulnerable to impairment charges, particularly newly acquired assets for recently launched products and IPR&D. Considering the high risk nature of research and development and the industry’s success rate of bringing developmental compounds to market, IPR&D impairment charges may occur in future periods. Estimating the fair value of IPR&D for potential impairment is highly sensitive to changes in projections and assumptions and changes in assumptions could potentially lead to impairment.

Upon obtaining regulatory approval, IPR&D assets are then accounted for as a finite-lived intangible asset and amortized on a straight-line basis over its estimated useful life. If the project is abandoned, the IPR&D asset is charged to expense. Finite lived intangible assets are tested for impairment when events or changes in circumstances indicate it is more likely than not that the carrying amount of such assets may not be recoverable. The testing includes a comparison of the carrying amount of the asset to its estimated undiscounted future cash flows expected to be generated by the asset. If the carrying amount of an asset exceeds its estimated undiscounted future cash flows, then an impairment charge is recognized for the amount by which the carrying amount of the asset exceeds the fair value of the asset.

We believe that our estimates and assumptions in testing goodwill and other intangible assets, including IPR&D, for

impairment are reasonable and otherwise consistent with assumptions that marketplace participants would use in their estimates

of fair value. However, if future results are not consistent with our estimates and assumptions, including as a result of the

COVID-19 global pandemic, then we may be exposed to additional impairment charges, which could be material. Pfizer submitted the initial BLA with the FDA for approval of Somatrogon (hGH-CTP) in the United States and Pfizer received a Complete Response Letter in January 2022. Pfizer and OPKO are evaluating the FDA’s comments and will work with the agency to determine the best path forward for Somatrogon (hGH-CTP) in the United States.

In the first quarter of 2022, we reclassified $590.0 million of IPR&D related to Somatrogon (hGH-CTP) from IPR&D in our Condensed Consolidated Balance Sheet upon the approval of NGENLA (Somatrogon) in Europe and Japan. The assets will be amortized on a straight-line basis over their estimated useful life of approximately 12 years.

We amortize intangible assets with definite lives on a straight-line basis over their estimated useful lives, ranging from 3 to 20 years. We use the straight-line method of amortization as there is no reliably determinable pattern in which the economic benefits of our intangible assets are consumed or otherwise used up. Amortization expense was $44.8 million and $25.2 million for the six months ended June 30, 2022 and 2021, respectively.

Fair value measurements. The carrying amounts of our cash and cash equivalents, accounts receivable, accounts payable and short-term debt approximate their fair value due to the short-term maturities of these instruments. Investments that are considered equity securities as of June 30, 2022 and December 31, 2021 are predominately carried at fair value. Our debt under the Credit Agreement (as defined below) approximates fair value due to the variable rate of interest applicable to such debt.

In evaluating the fair value information, considerable judgment is required to interpret the market data used to develop the estimates. The use of different market assumptions and/or different valuation techniques may have a material effect on the

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estimated fair value amounts. Accordingly, the estimates of fair value presented herein may not be indicative of the amounts that could be realized in a current market exchange. Refer to Note 9.

Contingent consideration. Each period we revalue the contingent consideration obligations associated with certain prior acquisitions to their fair value and record increases in the fair value as contingent consideration expense and decreases in the fair value as a reduction in contingent consideration expense. Changes in contingent consideration result from changes in the assumptions regarding probabilities of successful achievement of related milestones, the estimated timing in which the milestones are achieved and the discount rate used to estimate the fair value of the liability. Contingent consideration may change significantly as our development programs progress, revenue estimates evolve and additional data is obtained, impacting our assumptions. The assumptions used in estimating fair value require significant judgment. The use of different assumptions and judgments could result in a materially different estimate of fair value which may have a material impact on our results from operations and financial position.

Derivative financial instruments. We record derivative financial instruments on our Condensed Consolidated Balance Sheet at their fair value and recognize the changes in the fair value in our Condensed Consolidated Statement of Operations when they occur, the only exception being derivatives that qualify as hedges. For the derivative instrument to qualify as a hedge, we are required to meet strict hedge effectiveness and contemporaneous documentation requirements at the initiation of the hedge and assess the hedge effectiveness on an ongoing basis over the life of the hedge. At June 30, 2022 and December 31, 2021, our foreign currency forward contracts held to economically hedge inventory purchases did not meet the documentation requirements to be designated as hedges. Accordingly, we recognized all changes in the fair values of our derivatives instruments, net, in our Condensed Consolidated Statement of Operations. Refer to Note 10.

Property, plant and equipment. Property, plant and equipment are recorded at cost or fair value if acquired in a business combination. Depreciation is provided using the straight-line method over the estimated useful lives of the assets and includes amortization expense for assets capitalized under finance leases. The estimated useful lives by asset class are as follows: software - 3 years, machinery, medical and other equipment - 5-8 years, furniture and fixtures - 5-12 years, leasehold improvements - the lesser of their useful life or the lease term, buildings and improvements - 10-40 years, and automobiles - 3-5 years. Expenditures for repairs and maintenance are charged to expense as incurred. Assets held under finance leases are included within Property, plant and equipment, net in our Consolidated Balance Sheets and are amortized over the shorter of their useful lives or the expected term of their related leases. Depreciation expense was $5.2 million and $11.0 million for the three and six months ended June 30, 2022, respectively. Depreciation expense was $8.0 million and $15.4 million for three and six months ended June 30, 2021, respectively.

Impairment of long-lived assets. Long-lived assets, such as property and equipment and assets held for sale, are reviewed for impairment whenever events or changes in circumstances indicate that the carrying amount of an asset may not be recoverable. Recoverability of assets to be held and used is measured by a comparison of the carrying amount of an asset to estimated undiscounted future cash flows expected to be generated by the asset. If the carrying amount of an asset exceeds its estimated future cash flows, then an impairment charge is recognized for the amount by which the carrying amount of the asset exceeds the fair value of the asset.

Income taxes. Income taxes are accounted for under the asset-and-liability method. Deferred tax assets and liabilities are recognized for the future tax consequences attributable to differences between the financial statement carrying amounts of existing assets and liabilities and the respective tax bases and for operating loss and tax credit carryforwards. Deferred tax assets and liabilities are measured using enacted tax rates expected to apply to taxable income in the years in which those temporary differences are expected to be recovered or settled. The effect on deferred tax assets and liabilities of a change in tax rates is recognized in operations in the period that includes the enactment date. We periodically evaluate the realizability of our net deferred tax assets. Our tax accruals are analyzed periodically and adjustments are made as events occur to warrant such adjustment. Valuation allowances on certain U.S. deferred tax assets and non-U.S. deferred tax assets are established, because realization of these tax benefits through future taxable income does not meet the more-likely-than-not threshold.

We operate in various countries and tax jurisdictions globally.  For interim reporting purposes, we record income taxes based on the expected effective income tax rate, taking into consideration year to date and global forecasted tax results.  For the six months ended June 30, 2022, the tax rate differed from the U.S. federal statutory rate of 21% primarily due to the valuation allowance against certain U.S. and non-U.S. deferred tax assets, the relative mix in earnings and losses in the U.S. versus foreign tax jurisdictions, and the impact of certain discrete tax events and operating results in tax jurisdictions which do not result in a tax benefit.

Revenue recognition. We recognize revenue when a customer obtains control of promised goods or services in accordance with Accounting Standards Codification Topic 606, Revenue from Contracts with Customers (“Topic 606”). The amount of revenue that is recorded reflects the consideration that we expect to receive in exchange for those goods or services.

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We apply the following five-step model in order to determine this amount: (i) identify the contract(s) with a customer; (ii) identify the performance obligations in the contract; (iii) determine the transaction price; (iv) allocate the transaction price to the performance obligations in the contract; and (v) recognize revenue when (or as) we satisfy a performance obligation.

We apply the five-step model to contracts when it is probable that we will collect the consideration we are entitled to in exchange for the goods or services we transfer to the customer. At contract inception, once the contract is determined to be within the scope of Topic 606, we review the contract to determine which performance obligations we must deliver and which of these performance obligations are distinct. We recognize as revenue the amount of the transaction price that is allocated to the respective performance obligation when the performance obligation is satisfied or as it is satisfied. For a complete discussion of accounting for Revenues from services, Revenues from products and Revenue from transfer of intellectual property and other, refer to Note 13.

Concentration of credit risk and allowance for credit losses. Financial instruments that potentially subject us to concentrations of credit risk consist primarily of accounts receivable. Substantially all of our accounts receivable are with either companies in the healthcare industry or patients. However, credit risk is limited due to the number of our clients as well as their dispersion across many different geographic regions.

While we have receivables due from federal and state governmental agencies, we do not believe that such receivables represent a credit risk because the related healthcare programs are funded by federal and state governments, and payment is primarily dependent upon submitting appropriate documentation. On June 30, 2022 and December 31, 2021, receivable balances (net of explicit and implicit price concessions) from Medicare and Medicaid were 12% and 6%, respectively, of our consolidated Accounts receivable, net. On June 30, 2022 and December 31, 2021, receivable balances (net of explicit and implicit price concessions) due directly from states, cities and other municipalities, specifically related to our real-time reverse-transcription polymerase chain reaction (real-time RT-PCR) assay to detect COVID-19, were 3.9% and 4.1% of our consolidated accounts receivable, net, respectively.

The portion of our accounts receivable due from individual patients comprises the largest portion of credit risk. At June 30, 2022 and December 31, 2021, receivables due from patients represented approximately 2.3% and 0.7%, respectively, of our consolidated Accounts receivable, net.

We assess the collectability of accounts receivable balances by considering factors such as historical collection experience, customer credit worthiness, the age of accounts receivable balances, regulatory changes and current economic conditions and trends that may affect a customer’s ability to pay. Actual results could differ from those estimates. The allowance for credit losses was $6.8 million and $1.8 million at June 30, 2022 and December 31, 2021, respectively. The credit loss expense for the three and six months ended June 30, 2022 was $0.1 million and $0.2 million, respectively. The credit loss expense for the three and six months ended June 30, 2021 was $0.3 million and $0.6 million, respectively.

Equity-based compensation. We measure the cost of services received in exchange for an award of equity instruments based on the grant-date fair value of the award. That cost is recognized in the Condensed Consolidated Statement of Operations over the period during which an employee is required to provide service in exchange for the award. We record excess tax benefits realized from the exercise of stock options as cash flows from operations. For the three and six months ended June 30, 2022 we recorded $4.3 million and $11.9 million, respectively, of equity-based compensation expense. For the three and six months ended June 30, 2021 we recorded $3.5 million and $6.1 million, respectively, of equity-based compensation expense.

Research and development expenses. Research and development expenses include external and internal expenses. External expenses include clinical and non-clinical activities performed by contract research organizations, lab services, purchases of drug and diagnostic product materials and manufacturing development costs. Research and development employee-related expenses include salaries, benefits and equity-based compensation expense. Other internal research and development expenses are incurred to support overall research and development activities and include expenses related to general overhead and facilities. We expense these costs in the period in which they are incurred. We estimate our liabilities for research and development expenses in order to match the recognition of expenses to the period in which the actual services are received. As such, accrued liabilities related to third party research and development activities are recognized based upon our estimate of services received and degree of completion of the services in accordance with the specific third party contract.

Research and development expense includes costs for in-process research and development projects acquired in asset acquisitions which have not reached technological feasibility, and which have no alternative future use. For in-process research and development projects acquired in business combinations, the in-process research and development project is capitalized and evaluated for impairment until the development process has been completed. Once the development process has been completed the asset will be amortized over its remaining estimated useful life.

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Segment reporting. Our chief operating decision-maker (“CODM”) is Phillip Frost, M.D., our Chairman and Chief Executive Officer. Our CODM reviews our operating results and operating plans and makes resource allocation decisions on a Company-wide or aggregate basis. We manage our operations in two reportable segments, pharmaceutical and diagnostics. The pharmaceutical segment consists of our pharmaceutical operations in Chile, Mexico, Ireland, Israel and Spain, Rayaldee product sales and our pharmaceutical research and development. The diagnostics segment primarily consists of clinical and genomics laboratory operations through BioReference and point-of-care operations. There are no significant inter-segment sales. We evaluate the performance of each segment based on operating profit or loss. There is no inter-segment allocation of interest expense or income taxes. Refer to Note 15.

Shipping and handling costs. We do not charge customers for shipping and handling costs. Shipping and handling costs are classified as Cost of revenues in the Condensed Consolidated Statement of Operations.

Foreign currency translation. The financial statements of certain of our foreign operations are measured using the local currency as the functional currency. The local currency assets and liabilities are generally translated at the rate of exchange to the U.S. dollar on the balance sheet date and the local currency revenues and expenses are translated at average rates of exchange to the U.S. dollar during the reporting periods. Foreign currency transaction gains (losses) have been reflected as a component of Other income (expense), net within the Condensed Consolidated Statement of Operations and foreign currency translation gains (losses) have been included as a component of the Condensed Consolidated Statement of Comprehensive Income (Loss). During the three and six months ended June 30, 2022, we recorded $0.8 million and $1.8 million, respectively of transaction losses. During the three and six months ended June 30, 2021, we recorded $(0.4) million and $4.4 million, respectively, of transaction gains and losses.

Variable interest entities. The consolidation of a variable interest entity (“VIE”) is required when an enterprise has a controlling financial interest. A controlling financial interest in a VIE will have both of the following characteristics: (a) the power to direct the activities of a VIE that most significantly impact the VIE’s economic performance and (b) the obligation to absorb losses of the VIE that could potentially be significant to the VIE. Refer to Note 6.

Investments. We have made strategic investments in development stage and emerging companies. We record these investments as equity method investments or as equity securities based on our percentage of ownership and whether we have significant influence over the operations of the investees. For investments classified under the equity method of accounting, we record our proportionate share of their losses in Losses from investments in investees in our Condensed Consolidated Statement of Operations. Refer to Note 6. For investments classified as equity securities, we record changes in their fair value as Other income (expense) in our Condensed Consolidated Statement of Operations based on their closing price per share at the end of each reporting period, unless the equity security does not have a readily determinable fair value. Refer to Note 6.

Recently adopted accounting pronouncements.

In August 2020, the FASB issued ASU No. 2020-06, “Debt—Debt with Conversion and Other Options (Subtopic 470-20) and Derivatives and Hedging—Contracts in Entity's Own Equity (Subtopic 815-40).” ASU 2020-06 simplifies the accounting for convertible instruments by reducing the number of accounting models for convertible debt instruments and convertible preferred stock. The ASU is effective for public entities for fiscal years beginning after December 15, 2021, with early adoption permitted. As required, we adopted ASU 2020-06 on January 1, 2022 and used the modified retrospective approach for all convertible debt instruments at the beginning of the period of adoptions. Results for reporting periods beginning January 1, 2022 are presented under ASU 2020-06, while prior period amounts were not adjusted and continue to be reported in accordance with historic accounting guidance.

Under the modified approach, entities will apply the guidance to all financial instruments that are outstanding as of the beginning of the year of adoption with the cumulative effect recognized as an adjustment to the opening balance of retained earnings. ASU 2020-06 eliminates the cash conversion and beneficial conversion feature models in ASC 470-20 that require an issuer of certain convertible debt and preferred stock to separately account for embedded conversion features as a component of equity. The adoption of ASU 2020-06 at January 1, 2022 resulted in an increase of the Convertible notes of $21.6 million, a reduction of the Accumulated deficit of $17.5 million and a reduction of Additional paid-in capital of $39.1 million.

NOTE 4 EARNINGS (LOSS) PER SHARE

Basic income (loss) per share is computed by dividing our net income (loss) by the weighted average number of shares of our Common Stock outstanding during the period. Shares of Common Stock outstanding under the share lending arrangement entered into in conjunction with the 2025 Notes (as defined in Note 7) are excluded from the calculation of basic and diluted earnings per share because the borrower of the shares is required under the share lending arrangement to refund any dividends

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paid on the shares lent. Refer to Note 7. For diluted earnings per share, the dilutive impact of stock options and warrants is determined by applying the “treasury stock” method. The dilutive impact of the 2033 Senior Notes, the 2023 Convertible Notes and the 2025 Notes (each, as defined and discussed in Note 7) has been considered using the “if converted” method. For periods in which their effect would be antidilutive, no effect is given to Common Stock issuable under outstanding options or warrants or the potentially dilutive shares issuable pursuant to the 2033 Senior Notes, the 2023 Convertible Notes and the 2025 Notes in the dilutive computation.

A total of 56,605,791 and 64,292,882 potential shares of Common Stock were excluded from the calculation of diluted net loss per share for the three months ended June 30, 2022, and 2021, respectively, because their inclusion would be antidilutive. A total of 57,016,847 and 69,861,689 potential shares of Common Stock were excluded from the calculation of diluted net loss per share for the six months ended June 30, 2022, and 2021, respectively, because their inclusion would be antidilutive. A full presentation of diluted earnings per share has not been provided because the required adjustments to the numerator and denominator resulted in diluted earnings per share equivalent to basic earnings per share.

During the three months ended June 30, 2022, an aggregate of 789,063 options and warrants to purchase shares of our Common Stock were exercised, resulting in the issuance of 546,337 shares of Common Stock. Of the 789,063 options and warrants exercised, 242,726 shares of Common Stock were surrendered in lieu of a cash payment via the net exercise feature of such instruments.

During the six months ended June 30, 2022, an aggregate of 844,813 options and warrants to purchase shares of our Common Stock were exercised, resulting in the issuance of 602,087 shares of Common Stock. Of the 844,813 options and warrants exercised, 242,726 shares of Common Stock were surrendered in lieu of a cash payment via the net exercise feature of such instruments.

During the three months ended June 30, 2021, an aggregate of 63,625 options or warrants to purchase shares of our Common Stock were exercised, resulting in the issuance of 63,625 shares of Common Stock. Of the 63,625 options and warrants exercised, no shares of Common Stock were surrendered in lieu of a cash payment via the net exercise feature of such instruments.

During the six months ended June 30, 2021, an aggregate of 181,125 options or warrants to purchase shares of our Common Stock were exercised, resulting in the issuance of 181,125 shares of Common Stock. Of the 181,125 options and warrants exercised, no shares of Common Stock were surrendered in lieu of a cash payment via the net exercise feature of such instruments.

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NOTE 5 COMPOSITION OF CERTAIN FINANCIAL STATEMENT CAPTIONS

(In thousands)	June 30, 2022		December 31, 2021
Accounts receivable, net:
Accounts receivable	$	165,226	$	261,476
Less: allowance for credit losses	(6,801)		(1,839)
	$	158,425	$	259,637
Inventories, net:
Consumable supplies	$	37,054	$	39,447
Finished products	42,321		44,107
Work in-process	1,892		1,615
Raw materials	7,256		6,112
Less: inventory reserve	(5,217)		(4,779)
	$	83,306	$	86,502
Other current assets and prepaid expenses:
Taxes recoverable	$	5,442	$	5,598
Prepaid expenses	12,324		10,641
Prepaid insurance	7,166		4,383
Other receivables	11,273		353
Other	6,358		6,195
	$	42,563	$	27,170
Intangible assets, net:
Customer relationships	$	311,864	$	314,823
Technologies	822,323		246,101
Trade names	49,735		49,770
Covenants not to compete	12,907		12,920
Licenses	5,873		5,766
Product registrations	6,440		6,995
Other	5,755		6,128
Less: accumulated amortization	(352,488)		(320,820)
	$	862,409	$	321,683
Accrued expenses:
Inventory received but not invoiced	$	18,853	$	40,446
Commitments and contingencies	12,745		27,819
Employee benefits	34,368		45,939
Contract liabilities	257		258
Clinical trials	4,245		4,867
Contingent consideration	487		487
Finance leases short-term	2,625		2,257
Professional fees	4,116		2,121
Other	50,558		69,299
	$	128,254	$	193,493

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(In thousands)	June 30, 2022		December 31, 2021
Other long-term liabilities:
Contingent consideration	$	2,416	$	2,350
Mortgages and other debts payable	1,680		2,224
Finance leases long-term	4,588		2,924
Contract liabilities	192		208
Other	7,361		7,356
	$	16,237	$	15,062

Our intangible assets and goodwill relate principally to our completed acquisitions of OPKO Renal, OPKO Biologics, EirGen, BioReference and ModeX. We amortize intangible assets with definite lives on a straight-line basis over their estimated useful lives. The estimated useful lives by asset class are as follows: technologies - 7-17 years, customer relationships - 7-20 years, product registrations - 7-10 years, covenants not to compete - 5 years, trade names - 5-10 years, other 9-13 years. We do not anticipate capitalizing the cost of product registration renewals, rather we expect to expense these costs, as incurred. Our goodwill is not tax deductible for income tax purposes in any jurisdiction in which we operate.

As of December 31, 2021, GeneDx met the held-for-sale accounting criteria and its related assets and liabilities were recognized at the lower of carrying value or fair value less costs to sell in the consolidated balance sheet. In addition, at December 31, 2021, Assets held for sale included $151.8 million of goodwill related to GeneDx.

In the first quarter of 2022, we reclassified $590.0 million of IPR&D related to Somatrogon from IPR&D in our Condensed Consolidated Balance Sheet upon the approval of NGENLA (Somatrogon) in Europe and Japan. The assets will be amortized on a straight-line basis over their estimated useful life of approximately 12 years. Other changes in value of the intangible assets and goodwill during the six months ended June 30, 2022 and 2021 were primarily due to foreign currency fluctuations between the Chilean Peso, and the Euro against the U.S. dollar.

The following table summarizes the changes in Goodwill by reporting unit during the six months ended June 30, 2022.

	2022
(In thousands)	Gross goodwill at January 1		Cumulative impairment at January 1		Acquisitions and dispositions		Foreign exchange and other		Balance at June 30
Pharmaceuticals
CURNA	$	4,827	$	(4,827)			$	—	$	—
Rayaldee	86,554		—				(6,652)		79,902
FineTech	11,698		(11,698)				—		—
ModeX	—		—		65,786		—		65,786
OPKO Biologics	139,784		—				—		139,784
OPKO Chile	3,760		—				(301)		3,459
OPKO Health Europe	7,478		—				(589)		6,889
OPKO Mexico	100		(100)				—		—
Transition Therapeutics	3,421		(3,421)				—		—
Diagnostics
BioReference	434,809		—		(151,784)		—		283,025
OPKO Diagnostics	17,977		(17,977)				—		—
	$	710,408	$	(38,023)	$	(85,998)	$	(7,542)	$	578,845

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NOTE 6 ACQUISITIONS AND INVESTMENTS

ModeX Acquisition

On May 9, 2022, the Company entered into the ModeX Merger Agreement, pursuant to which ModeX survived the ModeX Merger as a wholly owned subsidiary of the Company. The Company paid the entirety of the $300.0 million purchase price pursuant to the issuance of the Consideration Shares to the former stockholders of ModeX. The Consideration Shares were valued at $219.4 million, based on the closing price per share of our Common Stock of $2.44 as reported by NASDAQ on the Closing Date. Included in the total purchase price of $221.7 million are $2.3 million of fully vested equity awards.

The following table summarizes the preliminary purchase price allocation and the estimated fair value of the net assets acquired and liabilities assumed at the date of acquisition. The purchase price allocation for the ModeX transaction is preliminary pending completion of the fair value analysis of acquired assets and liabilities:

(in thousands)	ModeX
Current assets
Cash and cash equivalents	$	218
Other assets	554
Property, plant and equipment	1,046
IPR&D assets	195,000
Goodwill	65,786
Accounts payable	(202)
Deferred tax liability	(40,740)
Total purchase price	$	221,662

Goodwill from the acquisition of ModeX principally relates to intangible assets that do not qualify for separate recognition (for instance, ModeX's assembled workforce) and the deferred tax liability generated as a result of the transaction. Goodwill is not tax deductible for income tax purposes and was assigned to the pharmaceutical reporting segment.

Our IPR&D assets will not be amortized until the underlying development programs are completed. Intangible assets are tested for impairment whenever events or changes in circumstances indicate that the carrying amount of such assets may not be recoverable, although IPR&D is required to be tested at least annually until the project is completed or abandoned. Upon obtaining regulatory approval, the IPR&D asset is then accounted for as a finite-lived intangible asset and amortized depending on pattern of future use.

Revenue and Net income (loss) in the Condensed Consolidated Statement of Operations for the six months ended June 30, 2022 includes revenue and net loss of ModeX from the date of acquisition to the six months ended June 30, 2022 of $0.0 million and $1.1 million, respectively.

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Investments

The following table reflects the accounting method, carrying value and underlying equity in net assets of our unconsolidated investments as of June 30, 2022 and December 31, 2021:

(in thousands)	As of June 30, 2022				As of December 31, 2021
Investment type	Investment Carrying Value		Underlying Equity in Net Assets		Investment Carrying Value		Underlying Equity in Net Assets
Equity method investments	$	173	$	4,822	$	263	$	3,577
Variable interest entity, equity method	797		2,417		816		3,043
Equity method investments - FV option	100,800				—
Equity securities	1,508				4,226
Equity securities with no readily determinable fair value	5,396				5,408
Warrants and options	11				16
Total carrying value of investments	$	108,685			$	10,729

Equity method investments

Our equity method investments, other than Sema4 disclosed below, consist of investments in Pharmsynthez (ownership 9%), Cocrystal Pharma, Inc. (“COCP”) (3%), Non-Invasive Monitoring Systems, Inc. (“NIMS”) (1%), Neovasc, Inc. (“Neovasc”) (1%), BioCardia, Inc. (“BioCardia”) (1%), Xenetic Biosciences, Inc. (“Xenetic”) (3%), and LeaderMed Health Group Limited (“LeaderMed”) (47%). The aggregate amount of assets, liabilities, and net losses of these equity method investees as of and for the six months ended June 30, 2022 were $212.4 million, $41.7 million, and $48.6 million, respectively. The aggregate amount of assets, liabilities, and net losses of our equity method investees as of and for the year ended December 31, 2021 were $223.6 million, $37.9 million, and $69.4 million, respectively. We have determined that we and/or our related parties have the ability to exercise significant influence over our equity method investments through our board representation and/or voting power. Accordingly, we account for our investment in these entities under the equity method and record our proportionate share of their losses in Loss from investments in investees in our Condensed Consolidated Statement of Operations. The aggregate value of our equity method investments based on the quoted market prices of their respective shares of common stock and the number of shares held by us as of June 30, 2022 and December 31, 2021 was $1.9 million and $4.5 million, respectively.

Equity method investments - FV option

On April 29, 2022, the Company sold GeneDx to Sema4 in accordance with the terms of the GeneDx Merger Agreement, pursuant to which Sema4 paid to the Company aggregate consideration of $150.0 million in cash (before deduction of transaction expenses and other customary purchase price adjustments), together with the Closing Shares of Sema4 Common Stock. As of June 30, 2022, we held 80 million shares of Sema4’s Class A common stock, representing an approximate 21.2% ownership interest.

Pursuant to the GeneDx Merger Agreement, the Company designated, and Sema4 nominated for election an individual to serve on the board of directors of Sema4, and such nominee was elected by Sema4’s stockholders to serve as a director until Sema4’s 2024 annual meeting of stockholders. As a result, we have determined that the Company or our related parties can exercise significant influence over the investee through our board representation or voting power. However, our influence is restricted by the Sema4 Shareholder Agreement, pursuant to which we have agreed to vote our shares of Sema4 Common Stock in accordance with the recommendation of Sema4’s board of directors for so long as we continue to hold at least 5% of the outstanding shares of Sema4 Common Stock. Our sole ability to influence the policy-making process is through our board representation. However, because we hold only one out of eleven seats on Sema4’s board of directors, our intention is that we will no longer have a designee serving on Sema4’s board of directors upon the expiration of the Sema4 Lock-Up Period. As such, OPKO is not actively participating in the policy-making process of Sema4. We elected to we account for our investment in Sema4 under the equity method fair value option and record gains and losses from changes in fair value in other income (expense), net in our Condensed Consolidated Statement of Operations. For the three and six months ended June 30, 2022, we recognized $71.2 million in net losses for fair value changes in our Sema4 investment.

Investments in Equity Securities

Our equity securities consist of investments in Phio Pharmaceuticals (“Phio”) (ownership 0.01%), VBI Vaccines Inc. (“VBI”) (1%), ChromaDex Corporation (“ChromaDex”) (0.1%), Eloxx Pharmaceuticals, Inc. (“Eloxx”) (1%), and CAMP4 Therapeutics Corporation (“CAMP4”) (2%) and HealthSnap, Inc. (7%). We have determined that our ownership, along with

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that of our related parties, does not provide us with significant influence over the operations of these investments. Accordingly, we account for our investment in these entities as equity securities, and we record changes in the fair value of these investments in Other income (expense) each reporting period when they have readily determinable fair value. Equity securities without a readily determinable fair value are adjusted to fair value when there is an observable price change. Net gains and losses on our equity securities for the six months ended June 30, 2022, and 2021 were as follows:

	For the six months ended June 30
(in thousands)	2022		2021
Equity Securities:
Net gains and losses recognized during the period on equity securities	$	(2,718)	$	1,408
Less: Net gains realized during the period on equity securities	—		(2,981)
Unrealized net gains and losses recognized during the period on equity securities still held at the reporting date	$	(2,718)	$	(1,573)

Sales of investments

Gains (losses) included in earnings from sales of our investments are recorded in Other income (expense), net in our Condensed Consolidated Statement of Operations. The cost of securities sold is based on the specific identification method.

Warrants and options

In addition to our equity method investments and equity securities, we hold options to purchase 47 thousand additional shares of BioCardia, all of which were vested as of June 30, 2022 and December 31, 2021, and 33 thousand and 0.7 million to purchase additional shares of COCP and InCellDx, respectively. We recorded the changes in the fair value of the options and warrants in Fair value changes of derivative instruments, net in our Condensed Consolidated Statement of Operations. We also recorded the fair value of the options and warrants in Investments, net in our Condensed Consolidated Balance Sheet. See further discussion of the Company’s options and warrants in Note 9 and Note 10.

Investments in variable interest entities

We have determined that we hold variable interests in LeaderMed and Zebra Biologics, Inc. (“Zebra”). We made this determination as a result of our assessment that they do not have sufficient resources to carry out their principal activities without additional financial support.

On September 14, 2021, we and LeaderMed, a pharmaceutical development company with operations based in Asia, announced the formation of a joint venture to develop, manufacture and commercialize two of OPKO’s clinical stage, long-acting drug products in Greater China and eight other Asian territories. Under the terms of the agreements, we have granted the joint venture exclusive rights to develop, manufacture and commercialize (a) OPK88003, an oxyntomodulin analog being developed for the treatment of obesity and diabetes, and (b) Factor VIIa-CTP, a novel long acting coagulation factor being developed to treat hemophilia, in exchange for 4,703 shares 47% ownership interest in the joint venture. In addition, we received an upfront payment of $1.0 million and will be reimbursed for clinical trial material and technical support we provide the joint venture.

In order to determine the primary beneficiary of the joint venture, we evaluated our investment and our related parties’ investment, as well as our investment combined with the related parties’ investment to identify if we had the power to direct the activities that most significantly impact the economic performance of the joint venture. Based on the capital structure, governing documents and overall business operations of the joint venture, we determined that, while a VIE, we do not have the power to direct the activities that most significantly impact the joint venture’s economic performance and do not have an obligation to fund expected losses. We did determine that we can significantly influence control of the joint venture through our board representation and voting power. Therefore, we have the ability to exercise significant influence over the joint venture’s operations and account for our investment in the joint venture under the equity method.

We own 1,260,000 shares of Zebra Series A-2 Preferred Stock and 900,000 shares of Zebra restricted common stock (ownership 29% at June 30, 2022). Zebra is a privately held biotechnology company focused on the discovery and development of biosuperior antibody therapeutics and complex drugs. Dr. Richard Lerner, M.D., a former member of our Board of Directors, is a founder of Zebra and, along with Dr. Frost, serves as a member of Zebra’s Board of Directors.

In order to determine the primary beneficiary of Zebra, we evaluated our investment and our related parties’ investment, as well as our investment combined with the related parties’ investment to identify if we had the power to direct the activities that most significantly impact the economic performance of Zebra. Based on the capital structure, governing documents and

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overall business operations of Zebra, we determined that, while a VIE, we do not have the power to direct the activities that most significantly impact Zebra’s economic performance and have no obligation to fund expected losses. We determined, however, that we can significantly influence control of Zebra through our board representation and voting power. Therefore, we have the ability to exercise significant influence over Zebra’s operations and account for our investment in Zebra under the equity method.

NOTE 7 DEBT    

As of June 30, 2022 and December 31, 2021, our debt consisted of the following:

(In thousands)	June 30, 2022		December 31, 2021
2025 Notes	$	141,537	$	119,360
2023 Convertible Notes	66,889		65,525
2033 Senior Notes	3,050		3,050
JP Morgan Chase	2,867		—
Chilean and Spanish lines of credit	15,351		13,672
Current portion of notes payable	771		1,022
Long term portion of notes payable	1,984		2,642
Total	$	232,449	$	205,272
Balance sheet captions
Convertible Notes	$	211,477	$	187,935
Current portion of lines of credit and notes payable	18,989		14,695
LT notes payable included in long-term liabilities	1,984		2,642
Total	$	232,449	$	205,272

In February 2019, we issued $200.0 million aggregate principal amount of Convertible Senior Notes due 2025 (the “2025 Notes”) in an underwritten public offering. The 2025 Notes bear interest at a rate of 4.50% per year, payable semiannually in arrears on February 15 and August 15 of each year. The notes mature on February 15, 2025, unless earlier repurchased, redeemed or converted.

Holders may convert their 2025 Notes into shares of Common Stock at their option at any time prior to the close of business on the business day immediately preceding November 15, 2024 only under the following circumstances: (1) during any calendar quarter commencing after the calendar quarter ended March 31, 2019 (and only during such calendar quarter), if the last reported sale price of our Common Stock for at least 20 trading days (whether or not consecutive) during a period of 30 consecutive trading days ending on the last trading day of the immediately preceding calendar quarter is greater than or equal to 130% of the conversion price on each applicable trading day; (2) during the five business day period after any five consecutive trading day period (the “measurement period”) in which the trading price per $1,000 principal amount of 2025 Notes for each trading day of the measurement period was less than 98% of the product of the last reported sale price of our Common Stock and the conversion rate on each such trading day; (3) if we call any or all of the 2025 Notes for redemption, at any time prior to the close of business on the scheduled trading day immediately preceding the redemption date; or (4) upon the occurrence of specified corporate events set forth in the indenture governing the 2025 Notes. On or after November 15, 2024, until the close of business on the business day immediately preceding the maturity date, holders of the 2025 Notes may convert their notes at any time, regardless of the foregoing conditions. Upon conversion, we will pay or deliver, as the case may be, cash, shares of our Common Stock, or a combination of cash and shares of our Common Stock, at our election.

The initial and current conversion rate for the 2025 Notes is 236.7424 shares of Common Stock per $1,000 principal amount of 2025 Notes (equivalent to a conversion price of approximately $4.22 per share of Common Stock). The conversion rate for the 2025 Notes is subject to adjustment in certain events but will not be adjusted for any accrued and unpaid interest. In addition, following certain corporate events that occur prior to the maturity date of the 2025 Notes or if we deliver a notice of redemption, in certain circumstances the indenture governing the 2025 Notes requires an increase in the conversion rate of the 2025 Notes for a holder who elects to convert its notes in connection with such a corporate event or notice of redemption, as the case may be.

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We may not redeem the 2025 Notes prior to February 15, 2022. We may redeem for cash any or all of the 2025 Notes, at our option, on or after February 15, 2022, if the last reported sale price of our Common Stock has been at least 130% of the then current conversion price for the notes for at least 20 trading days (whether or not consecutive) during any 30 consecutive trading day period (including the last trading day of such period) ending on, and including, the trading day immediately preceding the date on which we provide notice of redemption at a redemption price equal to 100% of the principal amount of the notes to be redeemed, plus accrued and unpaid interest to, but excluding, the redemption date. No sinking fund is provided for the 2025 Notes.

If we undergo a fundamental change, as defined in the indenture governing the 2025 Notes, prior to the maturity date of the 2025 Notes, holders may require us to repurchase for cash all or any portion of their notes at a repurchase price equal to 100% of the principal amount of the notes to be repurchased, plus accrued and unpaid interest to, but excluding, the fundamental change repurchase date. The 2025 Notes are our senior unsecured obligations and rank senior in right of payment to any of our indebtedness that is expressly subordinated in right of payment to the 2025 Notes; equal in right of payment to any of our existing and future liabilities that are not so subordinated; effectively junior in right of payment to any of our secured indebtedness to the extent of the value of the assets securing such indebtedness; and structurally junior to all indebtedness and other liabilities (including trade payables) of our current or future subsidiaries.

In May 2021, we entered into exchange agreements with certain holders of the 2025 Notes, pursuant to which the holders exchanged $55.4 million in aggregate principal amount of the outstanding 2025 Notes for 19,051,270 shares of our Common Stock (the “Exchange”). We recorded an $11.1 million non-cash loss related to the Exchange during the second quarter of 2021.

In conjunction with the issuance of the 2025 Notes, we agreed to loan up to 30,000,000 shares of our Common Stock to affiliates of the underwriter in order to assist investors in the 2025 Notes to hedge their position. Following consummation of the Exchange, the number of outstanding borrowed shares of Common Stock was reduced by approximately 8,105,175 shares. As of June 30, 2022 and December 31, 2021, a total of 21,144,825 and 21,144,825 shares remained outstanding under the share lending arrangement, respectively. We will not receive any of the proceeds from the sale of the borrowed shares, but we received a one-time nominal fee of $0.3 million for the newly issued shares. Shares of our Common Stock outstanding under the share lending arrangement are excluded from the calculation of basic and diluted earnings per share. See Note 4.

The following table sets forth information related to the 2025 Notes which is included in our Condensed Consolidated Balance Sheet as of June 30, 2022:

(In thousands)	2025 Senior Notes		Discount		Debt Issuance Cost		Total
Balance at December 31, 2021	$	144,580	$	(22,747)	$	(2,473)	$	119,360
Amortization of debt discount and debt issuance costs	—		—		534		534
Adoption of ASU 2020-06	$	—	$	22,747	$	(1,104)	$	21,643
Balance at June 30, 2022	$	144,580	$	—	$	(3,043)	$	141,537

In August 2020, the FASB issued ASU No. 2020-06, “Debt—Debt with Conversion and Other Options (Subtopic 470-20) and Derivatives and Hedging—Contracts in Entity's Own Equity (Subtopic 815-40).” ASU 2020-06 simplifies the accounting for convertible instruments by reducing the number of accounting models for convertible debt instruments and convertible preferred stock. The ASU is effective for public entities for fiscal years beginning after December 15, 2021, with early adoption permitted. As required, we adopted ASU 2020-06 on January 1, 2022 and used the modified retrospective approach for all convertible debt instruments at the beginning of the period of adoptions. Results for reporting periods beginning January 1, 2022 are presented under ASU 2020-06, while prior period amounts were not adjusted and continue to be reported in accordance with historic accounting guidance.

Under the modified approach, entities will apply the guidance to all financial instruments that are outstanding as of the beginning of the year of adoption with the cumulative effect recognized as an adjustment to the opening balance of retained earnings. ASU 2020-06 eliminates the cash conversion and beneficial conversion feature models in ASC 470-20 that require an issuer of certain convertible debt and preferred stock to separately account for embedded conversion features as a component of equity. The adoption of ASU 2020-06 at January 1, 2022 resulted in an increase of the Convertible notes of $21.6 million, a reduction of the Accumulated deficit of $17.5 million and a reduction of Additional paid-in capital of $39.1 million.

In February 2018, we issued a series of 5% Convertible Promissory Notes (the “2023 Convertible Notes”) in the aggregate principal amount of $55.0 million. The 2023 Convertible Notes mature five years following the date of issuance. Each holder of a 2023 Convertible Note has the option, from time to time, to convert all or any portion of the outstanding principal balance of such 2023 Convertible Note, together with accrued and unpaid interest thereon, into shares of our Common

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Stock at a conversion price of $5.00 per share. We may redeem all or any part of the then issued and outstanding 2023 Convertible Notes, together with accrued and unpaid interest thereon, pro rata among the holders, upon no fewer than 30 days, and no more than 60 days, notice to the holders. The 2023 Convertible Notes contain customary events of default and representations and warranties of OPKO.

Purchasers of the 2023 Convertible Notes included an affiliate of Dr. Phillip Frost, M.D., our Chairman and Chief Executive Officer, and Dr. Jane H. Hsiao, Ph.D., MBA, our Vice-Chairman and Chief Technical Officer.

In January 2013, we entered into note purchase agreements with respect to the issuance and sale of our 3.0% Senior Notes due 2033 (the “2033 Senior Notes”) in a private placement exempt from registration under the Securities Act. We issued the 2033 Senior Notes on January 30, 2013. The 2033 Senior Notes, which totaled $175.0 million in original principal amount, bear interest at the rate of 3.0% per year, payable semiannually on February 1 and August 1 of each year. The 2033 Senior Notes mature on February 1, 2033, unless earlier repurchased, redeemed or converted. Upon a fundamental change, as defined in the indenture governing the 2033 Senior Notes, subject to certain exceptions, the holders may require us to repurchase all or any portion of their 2033 Senior Notes for cash at a repurchase price equal to 100% of the principal amount of the 2033 Senior Notes being repurchased, plus any accrued and unpaid interest to, but not including, the related fundamental change repurchase date.

From 2013 to 2016, holders of the 2033 Senior Notes converted $143.2 million in aggregate principal amount into an aggregate of 21,539,873 shares of Common Stock. On February 1, 2019, approximately $28.8 million aggregate principal amount of 2033 Senior Notes were tendered by holders pursuant to such holders’ option to require us to repurchase the 2033 Senior Notes as set forth in the indenture, governing the 2033 Senior Notes, following which repurchase only $3.0 million aggregate principal amount of the 2033 Senior Notes remained outstanding. Holders of the remaining $3.0 million principal amount of the 2033 Senior Notes may require us to repurchase such notes for 100% of their principal amount, plus accrued and unpaid interest, on February 1, 2023, on February 1, 2028, or following the occurrence of a fundamental change as described above.

The terms of the 2033 Senior Notes, include, among others: (i) rights to convert the notes into shares of our Common Stock, including upon a fundamental change; and (ii) a coupon make-whole payment in the event of a conversion by the holders of the 2033 Senior Notes on or after February 1, 2017 but prior to February 1, 2019. We determined that these specific terms were embedded derivatives. Embedded derivatives are required to be separated from the host contract, the 2033 Senior Notes, and carried at fair value when: (a) the embedded derivative possesses economic characteristics that are not clearly and closely related to the economic characteristics of the host contract; and (b) a separate, stand-alone instrument with the same terms would qualify as a derivative instrument. We concluded that the embedded derivatives within the 2033 Senior Notes met these criteria and, as such, were valued separate and apart from the 2033 Senior Notes and recorded at fair value each reporting period.

For accounting and financial reporting purposes, we combined these embedded derivatives and valued them together as one unit of accounting. In 2017, certain terms of the embedded derivatives expired pursuant to the original agreement and the embedded derivatives no longer met the criteria to be separated from the host contract and, as a result, the embedded derivatives were no longer required to be valued separate and apart from the 2033 Senior Notes and were reclassified to additional paid in capital.

In November 2015, BioReference and certain of its subsidiaries entered into a credit agreement with JPMorgan Chase Bank, N.A. (“CB”), as lender and administrative agent, as amended (the “Credit Agreement”). As amended, the Credit Agreement provides for a $75.0 million secured revolving credit facility and includes a $20.0 million sub-facility for swingline loans and a $20.0 million sub-facility for the issuance of letters of credit.

The Credit Agreement is guaranteed by all of BioReference’s domestic subsidiaries and is also secured by substantially all assets of BioReference and its domestic subsidiaries, as well as a non-recourse pledge by us of our equity interest in BioReference. Availability under the Credit Agreement is based on a borrowing base composed of eligible accounts receivables of BioReference and certain of its subsidiaries, as specified therein. As of June 30, 2022, $53.1 million remained available for borrowing under the Credit Agreement. Principal under the Credit Agreement is due upon maturity on August 30, 2024.

At BioReference’s option, borrowings under the Credit Agreement (other than swingline loans) bear interest at (i) the CB floating rate (defined as the higher of (a) the prime rate and (b) the LIBOR rate (adjusted for statutory reserve requirements for Eurocurrency liabilities) for an interest period of one month plus 2.50%) plus an applicable margin of 0.75% or (ii) the LIBOR rate (adjusted for statutory reserve requirements for Eurocurrency liabilities) plus an applicable margin of 1.75%. Swingline loans will bear interest at the CB floating rate plus the applicable margin. The Credit Agreement also calls for other customary

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fees and charges, including an unused commitment fee of 0.375% if the average quarterly availability is 50% or more of the revolving commitment, or 0.25% if the average quarterly availability is less than or equal to 50% of the revolving commitments.

As of June 30, 2022 and December 31, 2021, $2.9 million and no amount, respectively, was outstanding under the Credit Agreement.

The Credit Agreement contains customary covenants and restrictions, including, without limitation, covenants that require BioReference and its subsidiaries to maintain a minimum fixed charge coverage ratio if availability under the new credit facility falls below a specified amount and to comply with laws and restrictions on the ability of BioReference and its subsidiaries to incur additional indebtedness or to pay dividends and make certain other distributions to the Company, subject to certain exceptions as specified therein. Failure to comply with these covenants would constitute an event of default under the Credit Agreement, notwithstanding the ability of BioReference to meet its debt service obligations. The Credit Agreement also includes various customary remedies for the lenders following an event of default, including the acceleration of repayment of outstanding amounts under the Credit Agreement and execution upon the collateral securing obligations under the Credit Agreement. Substantially all the assets of BioReference and its subsidiaries are restricted from sale, transfer, lease, disposal or distributions to the Company, subject to certain exceptions. As of June 30, 2022, BioReference and its subsidiaries had net assets of approximately $680.0 million, which included goodwill of $283.0 million and intangible assets of $195.9 million.

On April 29, 2022, the Credit Agreement was amended to, among other things, (i) waive specified defaults under the Credit Agreement resulting from certain internal reorganization transactions that resulted in both BioReference and GeneDx changing their respective forms of organization from New Jersey corporations to Delaware limited liability companies, (ii) provide for the disposition of GeneDx pursuant to the transactions contemplated by the GeneDx Merger Agreement, (iii) amend certain reporting requirements under the Credit Agreement and (iv) provide that the borrowers under the Credit Agreement may effect certain restricted payments to the extent necessary for their parent entities to pay income tax in respect of income earned by the borrowers.

In addition to the Credit Agreement, we had line of credit agreements with thirteen other financial institutions as of June 30, 2022 and eleven other financial institutions as of December 31, 2021 in the U.S., Chile and Spain. These lines of credit are used primarily as sources of working capital for inventory purchases.

The following table summarizes the amounts outstanding under the BioReference, Chilean and Spanish lines of credit:

(Dollars in thousands)				Balance Outstanding
Lender	Interest rate on borrowings at June 30, 2022	Credit line capacity		June 30, 2022		December 31, 2021
JPMorgan Chase	3.25%	$	75,000	$	2,867	$	—
Itau Bank	5.50%	1,900		1,293		1,603
Bank of Chile	6.60%	2,500		1,452		1,048
BICE Bank	5.50%	2,500		1,499		850
Scotiabank	5.00%	5,500		1,560		567
Santander Bank	5.50%	5,000		2,467		503
Security Bank	5.50%	1,400		2		1,111
Estado Bank	5.50%	4,000		2,682		2,540
BCI Bank	5.00%	2,500		2,400		2,515
Corpbanca	5.00%	—		—		2,935
International Bank	5.50%	1,500		845		—
Consoorcio Bank	5.00%	2,000		1,151		—
Banco De Sabadell	1.75%	522		—		—
Santander Bank	2.15%	522		—		—
Total		$	104,844	$	18,218	$	13,672

For both June 30, 2022 and December 31, 2021, the weighted average interest rate on our lines of credit was approximately 5.4%.

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At June 30, 2022 and December 31, 2021, we had notes payable and other debt (excluding the 2033 Senior Notes, the 2023 Convertible Notes, the 2025 Notes, the Credit Agreement and amounts outstanding under lines of credit described above) as follows:

(In thousands)	June 30, 2022		December 31, 2021
Current portion of notes payable	$	771	$	1,022
Other long-term liabilities	1,984		2,642
Total	$	2,755	$	3,664

The notes and other debt mature at various dates ranging from 2022 through 2026, bearing variable interest rates from 0.7% up to 3.8%. The weighted average interest rate on the notes and other debt was 1.5% on both June 30, 2022 and December 31, 2021. The notes are partially secured by our office space in Barcelona.

NOTE 8 ACCUMULATED OTHER COMPREHENSIVE LOSS

For the six months ended June 30, 2022, changes in Accumulated other comprehensive loss, net of tax, were as follows:

(In thousands)	Foreign currency translation
Balance at December 31, 2021	$	(30,495)
Other comprehensive loss	(18,676)
Balance at June 30, 2022	$	(49,171)

NOTE 9 FAIR VALUE MEASUREMENTS

We record fair values at an exit price, representing the amount that would be received to sell an asset or paid to transfer a liability in an orderly transaction between market participants. As such, fair value is a market-based measurement determined based on assumptions that market participants would use in pricing an asset or liability. We utilize a three-tier fair value hierarchy, which prioritizes the inputs used in measuring fair value. These tiers are: Level 1, defined as observable inputs such as quoted prices in active markets; Level 2, defined as inputs other than quoted prices in active markets that are either directly or indirectly observable; and Level 3, defined as unobservable inputs in which little or no market data exists, therefore requiring an entity to develop its own assumptions.

As of June 30, 2022, we had equity securities and an equity method fair value option (refer to Note 6), forward foreign currency exchange contracts for inventory purchases (refer to Note 10) and contingent consideration related to the acquisitions of CURNA, OPKO Diagnostics and OPKO Renal that are required to be measured at fair value on a recurring basis. In addition, in connection with our investment and our consulting agreement with BioCardia, we record the related BioCardia options at fair value as well as the warrants from COCP.

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Our financial assets and liabilities measured at fair value on a recurring basis are as follows:

	Fair value measurements as of June 30, 2022
(In thousands)	Quoted prices in active markets for identical assets (Level 1)		Significant other observable inputs (Level 2)		Significant unobservable inputs (Level 3)		Total
Assets:
Money market funds	$	131,658	$	—	$	—	$	131,658
Equity securities	1,508		—		—		1,508
Equity Method - FV option	100,800		—		—		100,800
Common stock options/warrants	—		11		—		11
Forward contracts	—		434		—		434
Total assets	$	233,966	$	445	$	—	$	234,411
Liabilities:
Contingent consideration	—		—		2,903		2,903
Total liabilities	$	—	$	—	$	2,903	$	2,903

	Fair value measurements as of December 31, 2021
(In thousands)	Quoted prices in active markets for identical assets (Level 1)		Significant other observable inputs (Level 2)		Significant unobservable inputs (Level 3)		Total
Assets:
Equity securities	$	4,226	$	—	$	—	$	4,226
Common stock options/warrants	—		16		—		16
Forward contracts	—		122		—		122
Total assets	$	4,226	$	138	$	—	$	4,364
Liabilities:
Contingent consideration	—		—		2,837		2,837
Total liabilities	$	—	$	—	$	2,837	$	2,837

The carrying amount and estimated fair value of our 2025 Notes, as well as the applicable fair value hierarchy tiers, are contained in the table below. The fair value of the 2025 Notes is determined using inputs other than quoted prices in active markets that are directly observable.

	June 30, 2022
(In thousands)	Carrying Value		Total Fair Value		Level 1		Level 2		Level 3
2025 Notes	$	141,537	$	145,163	$	—	$	145,163	$	—

There have been no transfers between Level 1 and Level 2 and no transfers to or from Level 3 of the fair value hierarchy.

As of June 30, 2022 and December 31, 2021, the carrying value of our other financial instrument assets approximates their fair value due to their short-term nature or variable rate of interest.

The following table reconciles the beginning and ending balances of our Level 3 assets and liabilities as of June 30, 2022:

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	June 30, 2022
(In thousands)	Contingent consideration
Balance at December 31, 2021	$	2,837
Change in fair value:
Included in results of operations	69
Foreign currency impact	(3)
Balance at June 30, 2022	$	2,903

The estimated fair values of our financial instruments have been determined by using available market information and what we believe to be appropriate valuation methodologies. We use the following methods and assumptions in estimating fair value:

Contingent consideration – We estimate the fair value of the contingent consideration utilizing a discounted cash flow model for the expected payments based on estimated timing and expected revenues. We use several discount rates depending on each type of contingent consideration related to OPKO Diagnostics, CURNA and OPKO Renal transactions. As of June 30, 2022, of the $2.9 million of contingent consideration, $0.5 million was recorded in Accrued expenses and $2.4 million was recorded in Other long-term liabilities. As of December 31, 2021, of the $2.8 million of contingent consideration, $0.5 million was recorded in Accrued expenses and $2.3 million was recorded in Other long-term liabilities. As a result of our execution of the CAMP4 Agreement (as defined in Note 14), we will have to pay a percentage of any payments received under the CAMP4 Agreement to the former CURNA stockholders.

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NOTE 10 DERIVATIVE CONTRACTS

The following table summarizes the fair values and the presentation of our derivative financial instruments in the Condensed Consolidated Balance Sheets:

(In thousands)	Balance Sheet Component	June 30, 2022		December 31, 2021
Derivative financial instruments:
Common Stock options/warrants	Investments, net	$	11	$	16
Forward contracts	Unrealized gains on forward contracts are recorded in Other current assets and prepaid expenses. Unrealized (losses) on forward contracts are recorded in Accrued expenses.	$	434	$	122

We enter into foreign currency forward exchange contracts with respect to the risk of exposure to exchange rate differences arising from inventory purchases on letters of credit. Under these forward contracts, for any rate above or below the fixed rate, we receive or pay the difference between the spot rate and the fixed rate for the given amount at the settlement date.

To qualify the derivative instrument as a hedge, we are required to meet strict hedge effectiveness and contemporaneous documentation requirements at the initiation of the hedge and assess the hedge effectiveness on an ongoing basis over the life of the hedge. At June 30, 2022 and December 31, 2021, our derivative financial instruments did not meet the documentation requirements to be designated as hedges. Accordingly, we recognize the changes in Fair value of derivative instruments, net in our Condensed Consolidated Statement of Operations. The following table summarizes the losses and gains recorded for the three and six months ended June 30, 2022 and 2021:

	Three months ended June 30,				Six months ended June 30,
(In thousands)	2022		2021		2022		2021
Derivative gain (loss):
Common Stock options/warrants	$	(4)	$	(26)	$	(5)	$	(6)
Forward contracts	342		(246)		211		(705)
Total	$	338	$	(272)	$	206	$	(711)

NOTE 11 RELATED PARTY TRANSACTIONS

In August 2020, GeneDx entered into an agreement with Mednax Services, Inc. (“Mednax Services”), a subsidiary of MEDNAX, Inc., (“MEDNAX”) pursuant to which the parties formed a joint venture under the brand Detect Genomix. GeneDx’s initial capital investment in Detect Genomix was $245,000 for which GeneDx received a 49% ownership interest in Detect Genomix, and Mednax Services contributed $255,000 in exchange for a 51% ownership interest in Detect Genomix. Adam Logal, the Company’s CFO, was the chair and sat on the Board of Managers of the joint venture. Mednax Services provided administrative services to the joint venture pursuant to an administrative services agreement. GeneDx provided laboratory services to the joint venture. Dr. Roger Medel, a director of the Company, is the former Chief Executive Officer of MEDNAX and Mednax Services. Dr. Medel continues to serve on the board of MEDNAX. The joint venture was dissolved in January 2022.

On April 29, 2022, upon consummation of the GeneDx Transaction, the Company entered into a Transition Services Agreement, dated as of April 29, 2022 (the “Transition Services Agreement”), with GeneDx (now a wholly owned subsidiary of Sema4), pursuant to which OPKO has agreed to provide, at cost, certain customary support services in respect of GeneDx’s business through December 31, 2022, subject to certain limited exceptions, with such services being in order to facilitate the GeneDx Transactions, including human resources, information technology support, and finance and accounting. As of June 30, 2022, the Company had incurred aggregate expenses of $335.3 thousand for services rendered under the Transition Services Agreement, for which the Company has an offsetting receivable of $167.2 thousand payable to the Company by GeneDx in accordance with the terms of the Transition Services Agreement.

The Company owns approximately 9% of Pharmsynthez and Pharmsynthez is Xenetic’s largest and controlling stockholder. Dr. Richard Lerner, a director of the Company until his death on December 2, 2021, was a co-inventor of Xenetic’s technology and received 31,240 shares of Xenetic upon the closing of the Xenetic transactions described above. Adam Logal, our Senior Vice President and Chief Financial Officer, is a director of Xenetic.

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We hold investments in Zebra (ownership 29%), Neovasc (1%), ChromaDex Corporation (0.1%), COCP (3%), NIMS (1%), Eloxx (1%), BioCardia (1%) and LeaderMed Health Group Limited (47%). These investments were considered related party transactions as a result of our executive management’s ownership interests and/or board representation in these entities. See further discussion of our investments in Note 6.

We lease office space from Frost Real Estate Holdings, LLC (“Frost Holdings”) in Miami, Florida, where our principal executive offices are located. Effective August 1, 2019, we entered into an amendment to our lease agreement with Frost Holdings. The lease, as amended, is for approximately 29,500 square feet of space. The lease provides for payments of approximately $89 thousand per month in the first year increasing annually to $101 thousand per month in the fifth year, plus applicable sales tax. The rent is inclusive of operating expenses, property taxes and parking.

Dr. Elias Zerhouni, our Vice Chairman and President, sits on the board of directors of Danaher Corporation (“Danaher”). Our subsidiary, BioReference, routinely procures products and services from several subsidiaries of Danaher, including Beckman Coulter, Integrated DNA Technologies Inc., and Leica Microsystems Inc., to which BioReference has paid $1.7 million, $0.1 million, and $0.3 million, respectively, through June 30, 2022.

BioReference purchases and uses certain products acquired from InCellDx, a company in which we hold a 29% minority interest.

We reimburse Dr. Frost for Company-related use by Dr. Frost and our other executives of an airplane owned by a company that is beneficially owned by Dr. Frost. We reimburse Dr. Frost for out-of-pocket operating costs for the use of the airplane by Dr. Frost or Company executives for Company-related business. We do not reimburse Dr. Frost for personal use of the airplane by Dr. Frost or any other executive. For the three and six months ended June 30, 2022, we reimbursed approximately $0 thousand and $30 thousand, respectively, for Company-related travel by Dr. Frost and other OPKO executives. For the three and six months ended June 30, 2021, we reimbursed approximately $0 thousand and $43 thousand, respectively, for Company-related travel by Dr. Frost and other OPKO executives.

NOTE 12 COMMITMENTS AND CONTINGENCIES

In connection with our acquisitions of CURNA, OPKO Diagnostics and OPKO Renal, we agreed to pay future consideration to the sellers upon the achievement of certain events. As a result, as of June 30, 2022, we recorded $2.9 million as contingent consideration, with $0.5 million recorded within Accrued expenses and $2.4 million recorded within Other long-term liabilities in the accompanying Condensed Consolidated Balance Sheets. Refer to Note 5 and Note 17.

On March 1, 2019, the Company received a Civil Investigative Demand (“CID”) from the U.S. Department of Justice (“DOJ”), Washington, DC. The CID sets forth document requests and interrogatories in connection with allegations that the Company and certain of its affiliates violated the False Claims Act and/or the Anti-Kickback Statute. On January 13, 2022, the Federal Government notified the U.S.D.C., Middle District Florida, Jacksonville Division, that it is declining to intervene in the matter but retains the right, via the Attorney General, to consent to any proposed dismissal of the action by the Court. On February 9, 2022, the States of Florida, Georgia, and Commonwealth of Massachusetts notified the U.S.D.C., Middle District Florida, Jacksonville Division, that they are declining to intervene in the matter. Notwithstanding the above declinations, on February 17, 2022, the Company was served with the Relator’s Summons and Complaint (“Complaint”), which had been previously sealed. The complaint alleges violations of the False Claims Act, the California Fraud Preventions Act, the Florida False Claims Act, the Massachusetts False Claims Act, the Georgia False Medicaid Claims Act, and illegal kickbacks. The Company is reviewing and assessing the allegations made in the Complaint and, at this point, has not determined whether there is any merit to these claims nor can it determine the extent of any potential liability. While management cannot predict the outcome of these matters at this time, the ultimate outcome could be material to our business, financial condition, results of operations, and cash flows.

As previously reported, BioReference receives and is routinely required to respond to CIDs in the ordinary course of business. On November 26, 2019, BioReference received a CID from the DOJ. The CID stated that the DOJ was investigating whether BioReference paid unlawful remuneration to health care practitioners in violation of the Anti-Kickback Statute or Stark law and thus submitted or caused to be submitted false claims to government health care programs in violation of the False Claims Act. The time period covered by the DOJ’s requests was January 1, 2011 through November 26, 2019. BioReference has fully cooperated with the DOJ by submitting the requested information and making current employees available for interviews, and the DOJ made a presentation to BioReference regarding its position. The parties have reached an agreement on the settlement amount, which is approximately $10 million, excluding attorney fees (refer to Note 17). As of June 30, 2022 and December 31, 2021, $10.5 million and $10.0 million was recorded in Accrued expenses, respectively.

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On April 8, 2019, MabVax Therapeutics Holdings, Inc. filed a lawsuit in the Superior Court of California, County of San Diego against a number of individuals and entities, including the Company, Dr. Frost, Steven Rubin, the Company’s Executive Vice President-Administration, and an entity affiliated with Dr. Frost, based on the allegations raised in the SEC Complaint. The lawsuit seeks an award for actual and punitive damages, pre- and post-judgment interest; that the defendants be required to make full disclosure and accounting of their interests and transactions in plaintiff’s securities; costs of the suit, and reasonable attorney’s fees; and such other legal and equitable relief as the Court may deem proper under the circumstances. On January 31, 2022, plaintiffs entered into a confidential mutual release and settlement agreement with the Company, Dr. Frost, Frost Gamma Investment Trust, and Steve Rubin, which has been approved by the United States Bankruptcy Court for the District of Delaware.

On April 5, 2019, former shareholders of Claros Diagnostics, Inc. filed a complaint in the Chancery Court of Delaware against the Company, alleging among other things, that the Company breached the Agreement and Plan of Merger dated October 13, 2011 by and among the Company, Claros Merger Subsidiary, LLC and Claros Diagnostics, Inc. (the “Claros Merger Agreement”): (i) by failing to make a milestone payment of $2.375 million (payable in OPKO Common Stock) upon obtaining FDA approval of the Claros PSA test; and (ii) by repudiating its obligations to make additional future milestone payments as required under the Claros Merger Agreement. In January 2021, the Company and the shareholder representative entered into a settlement agreement providing, among other things, that the Company pay the shareholders $1.2 million, which the Company has paid in full.

In April 2017, the Civil Division of the United States Attorney’s Office for the Southern District of New York (the “SDNY”) informed BioReference that it believed that, from 2008 to 2012, BioReference had, in violation of the False Claims Act, improperly billed Medicare and TRICARE (both are federal government healthcare programs) for clinical laboratory services provided to hospital inpatient beneficiaries at certain hospitals. In April 2019, the SDNY also informed BioReference that it believed that BioReference provided physicians subsidies for electronic health record systems prior to 2012 that violated regulations adopted by HHS in 2006 which allowed laboratories to provide these donations under certain conditions. BioReference and the SDNY reached a settlement with respect to these matters and a final settlement and release, including BioReference’s payment of an approximately $11.5 million settlement amount, was approved on September 22, 2020. The settlement amount has been paid. The amount of relator attorneys’ fees is currently being negotiated.

From time to time, we may receive inquiries, document requests, CIDs or subpoenas from the Department of Justice, OCR, CMS, various payors and fiscal intermediaries, and other state and federal regulators regarding investigations, audits and reviews. In addition to the matters discussed in this note, we are currently responding to CIDs, subpoenas, payor audits, and document requests for various matters relating to our laboratory operations. Some pending or threatened proceedings against us may involve potentially substantial amounts as well as the possibility of civil, criminal, or administrative fines, penalties, or other sanctions, which could be material. Settlements of suits involving the types of issues that we routinely confront may require monetary payments as well as corporate integrity agreements. Additionally, qui tam or “whistleblower” actions initiated under the civil False Claims Act may be pending but placed under seal by the court to comply with the False Claims Act’s requirements for filing such suits. Also, from time to time, we may detect issues of non-compliance with federal healthcare laws pertaining to claims submission and reimbursement practices and/or financial relationships with physicians, among other things. We may avail ourselves of various mechanisms to address these issues, including participation in voluntary disclosure protocols. Participating in voluntary disclosure protocols can have the potential for significant settlement obligations or even enforcement action. The Company generally has cooperated, and intends to continue to cooperate, with appropriate regulatory authorities as and when investigations, audits and inquiries arise.

We are a party to other litigation in the ordinary course of business. While we cannot predict the ultimate outcome of legal matters, we accrue a liability for legal contingencies when we believe that it is both probable that a liability has been incurred and that we can reasonably estimate the amount of the loss. It’s reasonably possible the ultimate liability could exceed amounts currently estimated and we review established accruals and adjust them to reflect ongoing negotiations, settlements, rulings, advice of legal counsel and other relevant information. To the extent new information is obtained and our views on the probable outcomes of claims, suits, assessments, investigations or legal proceedings change, changes in our accrued liabilities would be recorded in the period in which such determination is made. Because of the high degree of judgment involved in establishing loss estimates, the ultimate outcome of such matters will differ from our estimates and such differences may be material to our business, financial condition, results of operations, and cash flows.

At June 30, 2022, we were committed to make future purchases for inventory and other items in 2022 that occur in the ordinary course of business under various purchase arrangements with fixed purchase provisions aggregating approximately $197.2 million.

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NOTE 13 REVENUE RECOGNITION

We generate revenues from services, products and intellectual property as follows:

Revenue from services

Revenue for laboratory services is recognized at the time test results are reported, which approximates when services are provided and the performance obligations are satisfied. Services are provided to patients covered by various third-party payor programs including various managed care organizations, as well as the Medicare and Medicaid programs. Billings for services are included in revenue net of allowances for contractual discounts, allowances for differences between the amounts billed and estimated program payment amounts, and implicit price concessions provided to uninsured patients which are all elements of variable consideration.

The following are descriptions of our payors for laboratory services:

Healthcare Insurers. Reimbursements from healthcare insurers are based on negotiated fee-for-service schedules. Revenues consist of amounts billed, net of contractual allowances for differences between amounts billed and the estimated consideration we expect to receive from such payors, which considers historical denial and collection experience and the terms of our contractual arrangements. Adjustments to the allowances, based on actual receipts from the third-party payors, are recorded upon settlement.

Government Payors. Reimbursements from government payors are based on fee-for-service schedules set by governmental authorities, including traditional Medicare and Medicaid. Revenues consist of amounts billed, net of contractual allowances for differences between amounts billed and the estimated consideration we expect to receive from such payors, which considers historical denial and collection experience and the terms of our contractual arrangements. Adjustments to the allowances, based on actual receipts from the government payors, are recorded upon settlement.

Client Payors. Client payors include physicians, hospitals, employers, and other institutions for which services are performed on a wholesale basis, and are billed and recognized as revenue based on negotiated fee schedules. Client payors also include cities, states and companies for which BioReference provides COVID-19 testing services.

Patients. Uninsured patients are billed based on established patient fee schedules or fees negotiated with physicians on behalf of their patients. Insured patients (including amounts for coinsurance and deductible responsibilities) are billed based on fees negotiated with healthcare insurers. Collection of billings from patients is subject to credit risk and ability of the patients to pay. Revenues consist of amounts billed net of discounts provided to uninsured patients in accordance with our policies and implicit price concessions. Implicit price concessions represent differences between amounts billed and the estimated consideration that we expect to receive from patients, which considers historical collection experience and other factors including current market conditions. Adjustments to the estimated allowances, based on actual receipts from the patients, are recorded upon settlement.

The complexities and ambiguities of billing, reimbursement regulations and claims processing, as well as considerations unique to Medicare and Medicaid programs, require us to estimate the potential for retroactive adjustments as an element of variable consideration in the recognition of revenue in the period the related services are rendered. Actual amounts are adjusted in the period those adjustments become known. For the six months ended June 30, 2022, negative revenue adjustments due to changes in estimates of implicit price concessions for performance obligations satisfied in prior periods of $21.2 million were recognized. Revenue adjustments for the six months ended June 30, 2022 were primarily due to lower COVID-19 test reimbursement estimates. For the six months ended June 30, 2021, positive revenue adjustments due to changes in estimates of implicit price concessions for performance obligations satisfied in prior periods of $28.5 million were recognized. Revenue adjustments for the six months ended June 30, 2021 were primarily due to an increase in COVID-19 test reimbursement estimates.

Third-party payors, including government programs, may decide to deny payment or recoup payments for testing they contend were improperly billed or not medically necessary, against their coverage determinations, or for which they believe they have otherwise overpaid (including as a result of their own error), and we may be required to refund payments already received. Our revenues may be subject to retroactive adjustment as a result of these factors among others, including without limitation, differing interpretations of billing and coding guidance and changes by government agencies and payors in interpretations, requirements, and “conditions of participation” in various programs. We have processed requests for recoupment from third-party payors in the ordinary course of our business, and it is likely that we will continue to do so in the future. If a third-party payor denies payment for testing or recoups money from us in a later period, reimbursement for our testing could decline.

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As an integral part of our billing compliance program, we periodically assess our billing and coding practices, respond to payor audits on a routine basis, and investigate reported failures or suspected failures to comply with federal and state healthcare reimbursement requirements, as well as overpayment claims which may arise from time to time without fault on the part of the Company. We may have an obligation to reimburse Medicare, Medicaid, and third-party payors for overpayments regardless of fault. We have periodically identified and reported overpayments, reimbursed payors for overpayments and taken appropriate corrective action.

Settlements with third-party payors for retroactive adjustments due to audits, reviews or investigations are also considered variable consideration and are included in the determination of the estimated transaction price for providing services. These settlements are estimated based on the terms of the payment agreement with the payor, correspondence from the payor and our historical settlement activity, including an assessment of the probability a significant reversal of cumulative revenue recognized will occur when the uncertainty is subsequently resolved. Estimated settlements are adjusted in future periods as adjustments become known (that is, new information becomes available), or as years are settled or are no longer subject to such audits, reviews, and investigations. As of June 30, 2022 and December 31, 2021, we had liabilities of approximately $1.5 million and $5.0 million, respectively, within Accrued expenses and Other long-term liabilities related to reimbursements for payor overpayments.

The composition of revenue from services by payor for the three and six months ended June 30, 2022 and 2021 was as follows:

	Three months ended June 30,				Six months ended June 30,
(In thousands)	2022		2021		2022		2021
Healthcare insurers	$	76,442	$	109,084	$	172,269	$	273,913
Government payers	25,659		57,611		53,263		131,269
Client payers	80,931		225,936		240,021		488,845
Patients	3,772		4,566		7,849		10,122
Total	$	186,804	$	397,197	$	473,402	$	904,149

Revenue from products

We recognize revenue from product sales when a customer obtains control of promised goods or services. The amount of revenue that is recorded reflects the consideration that we expect to receive in exchange for those goods or services. Our estimates for sales returns and allowances are based upon the historical patterns of product returns and allowances taken, matched against the sales from which they originated, and our evaluation of specific factors that may increase or decrease the risk of product returns. Product revenues are recorded net of estimated rebates, chargebacks, discounts, co-pay assistance and other deductions (collectively, “Sales Deductions”) as well as estimated product returns which are all elements of variable consideration. Allowances are recorded as a reduction of revenue at the time product revenues are recognized. The actual amounts of consideration ultimately received may differ from our estimates. If actual results in the future vary from our estimates, we will adjust these estimates, which would affect Revenue from products in the period such variances become known.

Rayaldee is distributed in the U.S. principally through the retail pharmacy channel, which initiates with the largest wholesalers in the U.S. (collectively, “Rayaldee Customers”). In addition to distribution agreements with Rayaldee Customers, we have entered into arrangements with many healthcare providers and payors that provide for government-mandated and/or privately-negotiated rebates, chargebacks and discounts with respect to the purchase of Rayaldee.

We recognize revenue for shipments of Rayaldee at the time of delivery to customers after estimating Sales Deductions and product returns as elements of variable consideration utilizing historical information and market research projections. For the three and six months ended June 30, 2022, we recognized $6.2 million and $11.3 million, respectively, in net product revenue from sales of Rayaldee. For the three and six months ended June 30, 2021, we recognized $5.0 million and $10.8 million, respectively, in net product revenue from sales of Rayaldee.

The following table presents an analysis of product sales allowances and accruals for the three and six months ended June 30, 2022 and 2021:

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(In thousands)	Chargebacks, discounts, rebates and fees		Governmental		Returns		Total
Balance at March 31, 2022	$	1,588	$	5,282	$	2,333	$	9,203
Provision related to current period sales	3,411		5,442		308		9,161
Credits or payments made	(3,330)		(4,235)		(1,023)		(8,588)
Balance at June 30, 2022	$	1,669	$	6,489	$	1,618	$	9,776
Total gross Rayaldee sales							$	15,382
Provision for Rayaldee sales allowances and accruals as a percentage of gross Rayaldee sales							60%

(In thousands)	Chargebacks, discounts, rebates and fees		Governmental		Returns		Total
Balance at December 31, 2021	$	2,014	$	5,499	$	2,639	$	10,152
Provision related to current period sales	6,626		10,311		577		17,514
Credits or payments made	(6,971)		(9,321)		(1,598)		(17,890)
Balance at June 30, 2022	$	1,669	$	6,489	$	1,618	$	9,776
Total gross Rayaldee sales							$	28,861
Provision for Rayaldee sales allowances and accruals as a percentage of gross Rayaldee sales							61%

(In thousands)	Chargebacks, discounts, rebates and fees		Governmental		Returns		Total
Balance at March 31, 2021	$	1,693	$	6,209	$	3,487	$	11,389
Provision related to current period sales	3,724		7,061		322		11,107
Credits or payments made	(3,716)		(5,684)		(485)		(9,885)
Balance at June 30, 2021	$	1,701	$	7,586	$	3,324	$	12,611
Total gross Rayaldee sales							$	16,122
Provision for Rayaldee sales allowances and accruals as a percentage of gross Rayaldee sales							69%

(In thousands)	Chargebacks, discounts, rebates and fees		Governmental		Returns		Total
Balance at December 31, 2020	$	2,332	$	5,812	$	3,593	$	11,737
Provision related to current period sales	7,539		12,755		635		20,929
Credits or payments made	(8,170)		(10,981)		(904)		(20,055)
Balance at June 30, 2021	$	1,701	$	7,586	$	3,324	$	12,611
Total gross Rayaldee sales							$	31,767
Provision for Rayaldee sales allowances and accruals as a percentage of gross Rayaldee sales							66%

Taxes collected from customers related to revenues from services and revenues from products are excluded from revenues.

Revenue from intellectual property and other

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We recognize revenues from the transfer of intellectual property generated through license, development, collaboration and/or commercialization agreements. The terms of these agreements typically include payment to us for one or more of the following: non-refundable, up-front license fees; development and commercialization milestone payments; funding of research and/or development activities; and royalties on sales of licensed products. Revenue is recognized upon satisfaction of a performance obligation by transferring control of a good or service to the customer.

For research, development and/or commercialization agreements that result in revenues, we identify all material performance obligations, which may include a license to intellectual property and know-how, and research and development activities. In order to determine the transaction price, in addition to any upfront payment, we estimate the amount of variable consideration at the outset of the contract either utilizing the expected value or most likely amount method, depending on the facts and circumstances relative to the contract. We constrain (reduce) our estimates of variable consideration such that it is probable that a significant reversal of previously recognized revenue will not occur throughout the life of the contract. When determining if variable consideration should be constrained, we consider whether there are factors outside of our control that could result in a significant reversal of revenue. In making these assessments, we consider the likelihood and magnitude of a potential reversal of revenue. These estimates are re-assessed each reporting period as required.

Upfront License Fees: If a license to our intellectual property is determined to be functional intellectual property distinct from the other performance obligations identified in the arrangement, we recognize revenue from nonrefundable, upfront license fees based on the relative value prescribed to the license compared to the total value of the arrangement. The revenue is recognized when the license is transferred to the customer and the customer is able to use and benefit from the license. For licenses that are not distinct from other obligations identified in the arrangement, we utilize judgment to assess the nature of the combined performance obligation to determine whether the combined performance obligation is satisfied over time or at a point in time. If the combined performance obligation is satisfied over time, we apply an appropriate method of measuring progress for purposes of recognizing revenue from nonrefundable, upfront license fees. We evaluate the measure of progress each reporting period and, if necessary, adjust the measure of performance and related revenue recognition.

Development and Regulatory Milestone Payments: Depending on facts and circumstances, we may conclude that it is appropriate to include the milestone in the estimated transaction price or that it is appropriate to fully constrain the milestone. A milestone payment is included in the transaction price in the reporting period that we conclude that it is probable that recording revenue in the period will not result in a significant reversal in amounts recognized in future periods. We may record revenues from certain milestones in a reporting period before the milestone is achieved if we conclude that achievement of the milestone is probable and that recognition of revenue related to the milestone will not result in a significant reversal in amounts recognized in future periods. We record a corresponding contract asset when this conclusion is reached. Milestone payments that have been fully constrained are not included in the transaction price to date. These milestones remain fully constrained until we conclude that achievement of the milestone is probable and that recognition of revenue related to the milestone will not result in a significant reversal in amounts recognized in future periods. We re-evaluate the probability of achievement of such development milestones and any related constraint each reporting period. We adjust our estimate of the overall transaction price, including the amount of revenue recorded, if necessary.

Research and Development Activities: If we are entitled to reimbursement from our customers for specified research and development expenses, we account for them as separate performance obligations if distinct. We also determine whether the research and development funding would result in revenues or an offset to research and development expenses in accordance with provisions of gross or net revenue presentation. The corresponding revenues or offset to research and development expenses are recognized as the related performance obligations are satisfied.

Sales-based Milestone and Royalty Payments: Our customers may be required to pay us sales-based milestone payments or royalties on future sales of commercial products. We recognize revenues related to sales-based milestone and royalty payments upon the later to occur of (i) achievement of the customer’s underlying sales or (ii) satisfaction of any performance obligation(s) related to these sales, in each case assuming the license to our intellectual property is deemed to be the predominant item to which the sales-based milestones and/or royalties relate.

Other Potential Products and Services: Arrangements may include an option for license rights, future supply of drug substance or drug product for either clinical development or commercial supply at the licensee’s election. We assess if these options provide a material right to the licensee and if so, they are accounted for as separate performance obligations at the inception of the contract and revenue is recognized only if the option is exercised and products or services are subsequently delivered or when the rights expire. If the promise is based on market terms and not considered a material right, the option is accounted for if and when exercised. If we are entitled to additional payments when the licensee exercises these options, any additional payments are generally recorded in license or other revenues when the licensee obtains control of the goods, which is upon delivery.

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For the three and six months ended June 30, 2022, revenue from transfer of intellectual property and other reflects $2.3 million and $4.5 million of revenue related to the Pfizer Transaction (as defined below) and a $85.0 million regulatory milestone payments from Pfizer due from the commencement of sales from NGENLA (Somatrogon) in Europe and Japan. For the six months ended June 30, 2022, revenue from transfer of intellectual property and other includes $3.0 million related to a sales milestone from VFMCRP (as defined below). For the three and six months ended June 30, 2021, revenue from transfer of intellectual property principally reflects $2.8 million and $5.6 million of revenue, respectively, related to the Pfizer Transaction and a $5.0 million non-refundable upfront payment we have received under the Nicoya Agreement (as defined below).

Contract liabilities relate to cash consideration that OPKO receives in advance of satisfying the related performance obligations. Changes in the contractual liabilities balance during the six months ended June 30, 2022 are as follows:

(In thousands)
Balance at December 31, 2021	$	466
Balance at June 30, 2022	449
Revenue recognized in the period from:
Amounts included in contracts liability at the beginning of the period	17

NOTE 14 STRATEGIC ALLIANCES

LeaderMed

On September 14, 2021, we and LeaderMed Health Group Limited (“LeaderMed”), a pharmaceutical development company with operations based in Asia, announced the formation of a joint venture to develop, manufacture and commercialize two of OPKO’s clinical stage, long-acting drug products in Greater China and eight other Asian territories.

Under the terms of the agreements, we have granted the joint venture exclusive rights to develop, manufacture and commercialize (a) OPK88003, an oxyntomodulin analog being developed for the treatment of obesity and diabetes, and (b) Factor VIIa-CTP, a novel long-acting coagulation factor being developed to treat hemophilia, in exchange for a 47% ownership interest in the joint venture. In addition, we received an upfront payment of $1 million and will be reimbursed for clinical trial material and technical support we provide the joint venture. We recognized the upfront payment of $1 million as revenue from transfer of intellectual property and other during the year ended December 31, 2021.

LeaderMed has agreed to be responsible for funding the joint venture’s operations, development and commercialization efforts and, together with its syndicate partners, initially invested $11 million in exchange for a 53% ownership interest. We retain full rights to oxyntomodulin and Factor VIIa-CTP in all other geographies.

CAMP4 Therapeutics

On July 6, 2021, we entered into an exclusive license agreement (the “CAMP4 Agreement”) with CAMP4, pursuant to which we granted to CAMP4 an exclusive license to develop, manufacture, commercialize or improve therapeutics utilizing the AntagoNAT technology, an oligonucleotide platform developed under OPKO CURNA, which includes the molecule for the treatment of Dravet syndrome, together with any derivative or modification thereof (the “Licensed Compound”) and any pharmaceutical product that comprises or contains the Licensed Compound, alone or in combination with one or more other active ingredients (“Licensed Product”), worldwide. The CAMP4 Agreement grant covers human pharmaceutical, prophylactic, and therapeutic and certain diagnostic uses.

We received an initial upfront payment of $1.5 million and 3,373,008 shares of CAMP4’s Series A Prime Preferred Stock (“Preferred Stock”), which equates to approximately 9% of the outstanding shares of CAMP4, and we are eligible to receive up to $3.5 million in development milestone payments for Dravet syndrome products, and $4 million for non-Dravet syndrome products, as well as sales milestones of up to $90 million for Dravet syndrome products and up to $90 million for non-Dravet syndrome products. We may also receive double digit royalty payments on the net sales of royalty bearing products, subject to adjustment. In addition, upon achievement of certain development milestones, we will be eligible to receive equity consideration of up to 5,782,299 shares of Preferred Stock in connection with Dravet syndrome products and up to 1,082,248 shares of Preferred Stock in connection with non-Dravet syndrome products. In connection with our acquisition of CURNA, we agreed to pay future consideration to the sellers upon the achievement of certain events. As a result of our execution of the CAMP4 Agreement, we will have to pay a percentage of any payments received under the CAMP4 Agreement to the former CURNA stockholders.

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Unless earlier terminated, the CAMP4 Agreement will remain in effect on a Licensed Product-by-Licensed Product and country by-country basis until such time as the royalty term expires for a Licensed Product in a country, and expires in its entirety upon the expiration of the royalty term for the last Licensed Product in the last country. CAMP4’s royalty obligations expire on the later of (i) the expiration, invalidation or abandonment date of the last patent right in connection with the royalty bearing product, or (ii) ten (10) years after a royalty bearing product’s first commercial sale in a country. In addition to termination rights for material breach and bankruptcy, CAMP4 is permitted to terminate the Agreement after a specified notice period.

NICOYA Macau Limited

On June 18, 2021, EirGen, our wholly owned subsidiary, and NICOYA Macau Limited (“Nicoya”), a Macau corporation and an affiliate of NICOYA Therapeutics, entered into a Development and License Agreement (the “Nicoya Agreement”) granting Nicoya the exclusive rights for the development and commercialization of extended release calcifediol (the “Nicoya Product”) in Greater China, which includes mainland China, Hong Kong, Macau, and Taiwan (collectively, the “Nicoya Territory”). Extended release calcifediol is marketed in the U.S. by OPKO under the tradename Rayaldee. The license grant to Nicoya covers the therapeutic and preventative use of the Nicoya Product for SHPT in non-dialysis and hemodialysis chronic kidney disease patients (the “Nicoya Field”).

EirGen has received an initial upfront payment of $5 million and is eligible to receive an additional $5 million upon the first to occur of (A) a predetermined milestone and (B) the first anniversary of the effective date. EirGen is also eligible to receive up to an additional aggregate amount of $115 million upon the achievement of certain development, regulatory and sales-based milestones by Nicoya for the Nicoya Product in the Nicoya Territory. EirGen will also receive tiered, double digit royalty payments at rates in the low double digits on net product sales within the Nicoya Territory and in the Nicoya Field.

Nicoya will, at its sole cost and expense, be responsible for performing all development activities necessary to obtain all regulatory approvals for the Nicoya Product in the Nicoya Territory and for all commercial activities pertaining to the Nicoya Product in the Nicoya Territory.

Unless earlier terminated, the Nicoya Agreement will remain in effect until such time as all royalty payment terms and extended payment terms have expired, and Nicoya shall have no further payment obligations to EirGen under the terms of the Nicoya Agreement. Nicoya’s royalty obligations expire on the later of (i) expiration of the last to expire valid patent claim covering the Nicoya Product sold in the Nicoya Territory, (ii) expiration of all regulatory and data exclusivity applicable to the Nicoya Product in the Nicoya Territory, and (iii) on a product-by-product basis, ten (10) years after such Nicoya Product’s first commercial sale in the Nicoya Territory. In addition to termination rights for material breach and bankruptcy, Nicoya is permitted to terminate the Nicoya Agreement after a specified notice period.

Vifor Fresenius Medical Care Renal Pharma Ltd

In May 2016, EirGen and Vifor Fresenius Medical Care Renal Pharma Ltd. (“VFMCRP”) entered into a Development and License Agreement (the “VFMCRP Agreement”) for the development and commercialization of Rayaldee (the “Product”) worldwide, except for (i) the U.S., (ii) any country in Central America or South America (including Mexico), (iii) Russia, (iv) China, (v) South Korea, (vi) Ukraine, (vii) Belorussia, (viii) Azerbaijan, (ix) Kazakhstan, (x) Taiwan (xi) the Middle East, and (xii) all countries of Africa (the “VFMCRP Territory”), as amended. The license to VFMCRP potentially covers all therapeutic and prophylactic uses of the Product in human patients (the “VFMCRP Field”), provided that initially the license is for the use of the Product for the treatment or prevention of SHPT related to patients with CKD and vitamin D insufficiency/deficiency (the “VFMCRP Initial Indication”).

For the six months ended June 30, 2022 we recognized a milestone payment of $3.0 million in revenue from transfer of intellectual property and other for the first sale of Rayaldee in Europe.

Effective May 23, 2021, we entered into an amendment to the VFMCRP Agreement pursuant to which the parties thereto agreed to include Japan as part of the VFMCRP Territory.

Effective May 5, 2020, we entered into an amendment to the VFMCRP Agreement pursuant to which the parties agreed to exclude Mexico, South Korea, the Middle East and all of the countries of Africa from the VFMCRP Territory. In addition, the parties agreed to certain amendments to the milestone structure and to reduce minimum royalties payable. As revised, the Company has received a $3 million payment triggered by the first marketing approval of Rayaldee in Europe and is eligible to receive up to an additional $17 million in regulatory milestones and $207 million in milestone payments tied to launch, pricing and sales of Rayaldee, and tiered, double-digit royalties.

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We plan to share responsibility with VFMCRP for the conduct of trials specified within an agreed-upon development plan, with each company leading certain activities within the plan. EirGen will lead the manufacturing activities within and outside the VFMCRP Territory and the commercialization activities outside the VFMCRP Territory and outside the VFMCRP Field in the VFMCRP Territory and VFMCRP will lead the commercialization activities in the VFMCRP Territory and the VFMCRP Field. For the initial development plan, the companies have agreed to certain cost sharing arrangements. VFMCRP will be responsible for all other development costs that VFMCRP considers necessary to develop the Product for the use of the Product for the VFMCRP Initial Indication in the VFMCRP Territory in the VFMCRP Field except as otherwise provided in the VFMCRP Agreement. The first of the clinical studies provided for in the development activities commenced in September 2018.

In connection with the VFMCRP Agreement, the parties entered into a letter agreement pursuant to which EirGen granted to VFMCRP an exclusive option (the “Option”) to acquire an exclusive license under certain EirGen patents and technology to use, import, offer for sale, sell, distribute and commercialize the Product in the U.S. solely for the treatment of SHPT in dialysis patients with CKD and vitamin D insufficiency (the “Dialysis Indication”). Upon exercise of the Option, VFMCRP will reimburse EirGen for all of the development costs incurred by EirGen with respect to the Product for the Dialysis Indication in the U.S. VFMCRP would also pay EirGen up to an additional aggregate amount of $555 million of sales-based milestones upon the achievement of certain milestones and would be obligated to pay royalties at percentage rates that range from the mid-teens to the mid-twenties on sales of the Product in the U.S. for the Dialysis Indication. To date, VFMCRP has not exercised its option.

Payments received for regulatory milestones and sales milestones are non-refundable. The regulatory milestones are payable if and when VFMCRP obtains approval from certain regulatory authorities and will be recognized as revenue in the period in which the associated milestone is achieved, assuming all other revenue recognition criteria are met. We account for the sales milestones as royalties and sales milestones payments will be recognized as revenue in the period in which the associated milestone is achieved or sales occur, assuming all other revenue recognition criteria are met.

Pfizer Inc.

In December 2014, we entered into an exclusive worldwide agreement (the “Pfizer Agreement”) with Pfizer for the development and commercialization of our long-acting Somatrogon (hGH-CTP) for the treatment of growth hormone deficiency (“GHD”) in adults and children, as well as for the treatment of growth failure in children born small for gestational age (the “Pfizer Transaction”).

In early 2022, the European Commission and Ministry of Health, Labour and Welfare in Japan approved the next-generation long-acting recombinant human growth hormone NGENLA (Somatrogon), a once-weekly injection to treat pediatric growth hormone deficiency, and we received pricing approvals in Germany and Japan. With the achievement of these milestones, we received $85.0 million in milestone payments during the second quarter of 2022. Further, Canada and Australia approved NGENLA in October and November of 2021, respectively.

In January 2022, the FDA issued a Complete Response Letter for the BLA for Somatrogon (hGH-CTP). Pfizer and OPKO are evaluating the FDA’s comments and will work with the agency to determine the best path forward for Somatrogon (hGH-CTP) in the United States.

In May 2020, we entered into an Amended and Restated Development and Commercialization License Agreement (the “Restated Pfizer Agreement”) with Pfizer, effective January 1, 2020, pursuant to which the parties agreed, among other things, to share all costs for Manufacturing Activities, as defined in the Restated Pfizer Agreement, for developing a licensed product for the three indications included in the Restated Pfizer Agreement.

On October 21, 2019, we and Pfizer announced that the global phase 3 trial evaluating Somatrogon dosed once-weekly in prepubertal children with GHD met its primary endpoint of non-inferiority to daily Genotropin® (somatropin) for injection, as measured by annual height velocity at 12 months.

Under the terms of the Pfizer Transaction, as restated, we received non-refundable and non-creditable upfront payments of $295.0 million and are eligible to receive up to an additional $275.0 million upon the achievement of certain regulatory milestones. Pfizer received the exclusive license to commercialize Somatrogon worldwide. In addition, we are eligible to receive initial tiered royalty payments associated with the commercialization of Somatrogon for adult GHD with percentage rates ranging from the high teens to mid-twenties. Upon the launch of Somatrogon for pediatric GHD in certain major markets, the royalties will transition to regional, tiered gross profit sharing for both Somatrogon and Pfizer’s Genotropin®.

The agreement with Pfizer will remain in effect until the last sale of the licensed product, unless earlier terminated as permitted under the Pfizer Agreement. In addition to termination rights for material breach and bankruptcy, Pfizer is permitted

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to terminate the Pfizer Agreement in its entirety, or with respect to one or more world regions, without cause after a specified notice period. If the Pfizer Agreement is terminated by us for Pfizer’s uncured material breach, or by Pfizer without cause, provision has been made for transition of product and product responsibilities to us for the terminated regions, as well as continued supply of product by Pfizer or transfer of supply to us in order to support the terminated regions.

We recognized the non-refundable $295.0 million upfront payments as revenue as the research and development services were completed and as of both June 30, 2022 and December 31, 2021, we had no contract liabilities related to the Pfizer Transaction.

The Pfizer Transaction includes milestone payments of $275.0 million upon the achievement of certain milestones. The milestones range from $20.0 million to $90.0 million each and are based on achievement of regulatory approval in the U.S. and regulatory approval and price approval in other major markets. The milestone payments will be recognized as revenue in the period in which the associated milestone is achieved, assuming all other revenue recognition criteria are met. To date, $85.0 million of revenue has been recognized related to the achievement of the milestones.

Other

We have completed strategic deals with numerous institutions and commercial partners. In connection with these agreements, upon the achievement of certain milestones we are obligated to make certain payments and have royalty obligations upon sales of products developed under the license agreements. At this time, we are unable to estimate the timing and amounts of payments as the obligations are based on future development of the licensed products.

NOTE 15 SEGMENTS

We manage our operations in two reportable segments, pharmaceutical and diagnostics. The pharmaceutical segment consists of our pharmaceutical operations in Chile, Mexico, Ireland, Israel and Spain, Rayaldee product sales and our pharmaceutical research and development. The diagnostics segment primarily consists of our clinical and genomics laboratory operations through BioReference and our point-of-care operations. There are no significant inter-segment sales. We evaluate the performance of each segment based on operating profit or loss. There is no inter-segment allocation of interest expense and income taxes.

Information regarding our operations and assets for our operating segments and the unallocated corporate operations as well as geographic information are as follows:

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	For the three months ended June 30,				For the six months ended June 30,
(In thousands)	2022		2021		2022		2021
Revenue from services:
Pharmaceutical	$	—	$	—	$	—	$	—
Diagnostics	186,804		397,197		473,402		904,149
Corporate	—		—		—		—
	$	186,804	$	397,197	$	473,402	$	904,149
Revenue from products:
Pharmaceutical	$	35,892	$	35,663	$	72,550	$	69,608
Diagnostics	—		—		—		—
Corporate	—		—		—		—
	$	35,892	$	35,663	$	72,550	$	69,608
Revenue from transfer of intellectual property and other:
Pharmaceutical	$	87,197	$	9,548	$	93,159	$	13,816
Diagnostics	—		—		—		—
Corporate	—		—		—		—
	$	87,197	$	9,548	$	93,159	$	13,816
Operating income (loss):
Pharmaceutical	$	55,435	$	(13,710)	$	37,327	$	(32,868)
Diagnostics	(57,543)		30,000		(101,092)		97,014
Corporate	(8,631)		(10,719)		(19,399)		(20,138)
	$	(10,739)	$	5,571	$	(83,164)	$	44,008
Depreciation and amortization:
Pharmaceutical	$	17,840	$	7,007	$	33,242	$	14,420
Diagnostics	10,155		13,566		22,567		26,141
Corporate	—		—		—		—
	$	27,995	$	20,573	$	55,809	$	40,561
Loss from investment in investees:
Pharmaceutical	$	(268)	$	(67)	$	(316)	$	(110)
Diagnostics	—		—		—		—
Corporate	—		—		—		—
	$	(268)	$	(67)	$	(316)	$	(110)
Revenues:
United States	$	193,105	$	402,291	$	484,913	$	915,163
Ireland	89,177		12,088		97,638		19,218
Chile	15,804		18,657		32,143		32,809
Spain	5,696		5,437		12,805		11,356
Israel	1,854		724		3,412		3,235
Mexico	4,055		3,039		7,805		5,457
Other	202		172		395		335
	$	309,893	$	442,408	$	639,111	$	987,573

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(In thousands)	June 30, 2022		December 31, 2021
Assets:
Pharmaceutical	$	1,354,058	$	1,114,460
Diagnostics	748,165		1,238,583
Corporate	267,379		46,672
	$	2,369,602	$	2,399,715
Goodwill:
Pharmaceutical	$	295,820	$	237,576
Diagnostics	283,025		283,025
	$	578,845	$	520,601

No customer represented more than 10% of our total consolidated revenue during the six months ended June 30, 2022 and 2021. As of June 30, 2022 and December 31, 2021, no customer represented more than 10% of our accounts receivable balance.

NOTE 16 LEASES

We have operating leases for office space, laboratory operations, research and development facilities, manufacturing locations, warehouses and certain equipment. We determine if a contract contains a lease at inception or modification of a contract. Our leases generally do not provide an implicit interest rate, and we therefore use our incremental borrowing rate as the discount rate when measuring operating lease liabilities. The incremental borrowing rate represents an estimate of the interest rate we would incur at lease commencement to borrow an amount equal to the lease payments on a collateralized basis over the term of the lease within a particular currency environment. We used the incremental borrowing rates as of January 1, 2019 for operating leases that commenced prior to that date. Many of our leases contain rental escalation, renewal options and/or termination options that are factored into our determination of lease payments as appropriate. Variable lease payment amounts that cannot be determined at the commencement of the lease are not included in the right-to-use assets or liabilities.

We elected the use of permitted practical expedients of not recording leases on our Consolidated Balance Sheet when the leases have terms of 12 months or less, and we elected not to separate nonlease components from lease components and instead account for each separate lease component and the nonlease components associated with that lease component as a single lease component.

The following table presents the lease balances within the Condensed Consolidated Balance Sheet as of June 30, 2022 and December 31, 2021:

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(in thousands)	Classification on the Balance Sheet	June 30, 2022			December 31, 2021
Assets
Operating lease assets	Operating lease right-of-use assets	$	42,412		$	44,228
Finance lease assets	Property, plant and equipment, net	7,213			5,181
Liabilities
Current
Operating lease liabilities	Current maturities of operating leases	12,122			11,624
Accrued expenses	Current maturities of finance leases	2,625			2,257
Long-term
Operating lease liabilities	Operating lease liabilities	30,876			33,097
Other long-term liabilities	Finance lease liabilities	$	4,588		$	2,924
Weighted average remaining lease term
Operating leases		6.4 years			7.2 years
Finance leases		3.2 years			2.4 years
Weighted average discount rate
Operating leases		3.7		%	4.6		%
Finance leases		7.0		%	4.8		%

The following table reconciles the undiscounted future minimum lease payments (displayed by year and in the aggregate) under noncancelable operating leases with terms of more than one year to the total operating lease liabilities recognized on our Condensed Consolidated Balance Sheet as of June 30, 2022:

(in thousands)	Operating		Finance
July 1, 2022 through December 31, 2022	$	6,322	$	1,528
2023	10,399		2,430
2024	7,025		1,829
2025	4,541		1,291
2026	3,654		636
Thereafter	15,493		2
Total undiscounted future minimum lease payments	47,434		7,716
Less: Difference between lease payments and discounted lease liabilities	4,436		503
Total lease liabilities	$	42,998	$	7,213

Expense under operating leases and finance leases was $8.4 million and $1.9 million, respectively, for the six months ended June 30, 2022, which includes $1.3 million of variable lease costs. Expense under operating leases and finance leases was $9.1 million and $1.1 million, respectively, for the six months ended June 30, 2021, which includes $1.4 million of variable lease costs. Operating lease costs and finance lease costs are included within Operating loss in the Condensed Consolidated Statement of Operations. Short-term lease costs were not material.

Supplemental cash flow information is as follows:

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(in thousands)	For the six months ended June 30,
	2022		2021
Operating cash out flows from operating leases	$	8,327	$	6,484
Operating cash out flows from finance leases	52		45
Financing cash out flows from finance leases	724		769
Total	$	9,103	$	7,298

NOTE 17 SUBSEQUENT EVENTS

The Company and BioReference entered into (i) a settlement agreement (the “Settlement Agreement”), effective July 14, 2022, with the United States of America, acting through the United States Department of Justice and on behalf of the Office of Inspector General of the Department of Health and Human Services (“OIG-HHS”), and the Defense Health Agency, acting on behalf of the TRICARE Program (collectively, the “United States”), the Commonwealth of Massachusetts (the “Commonwealth”), the State of Connecticut, (“Connecticut”), and the relator identified therein (“Relator”), and (ii) a Corporate Integrity Agreement, effective July 14, 2022 (the “CIA”), with the OIG-HHS, to resolve the investigation and related civil action concerning alleged fee-for-service claims for payment to the Medicare Program, the Medicaid Program, and the TRICARE Program (collectively, the “Federal Health Care Programs”).

Under the Settlement Agreement, the Company and BioReference admitted only to having made payments to certain physicians and physicians’ groups for office space rentals for amounts that exceeded fair market value, and that it did not report or return any such overpayments to the Federal Health Care Programs (the “Covered Conduct”). The Covered Conduct had commenced prior to the Company’s acquisition of BioReference in 2015. With the exception of the Covered Conduct, the Company and BioReference expressly deny the allegations of the Relator as set forth in her civil action. The Company has agreed to pay a total of $10,000,000 plus accrued interest from September 24, 2021 at a rate of 1.5% per annum (the “Settlement Amount”). The Settlement Amount consists of $9,853,958 payable to the United States, $141,041 payable to the Commonwealth and $5,001 payable to Connecticut, in each case plus interest and paid on July 18th, 2022. Conditioned upon payment of the Settlement Amount, the United States, the Commonwealth and Connecticut have agreed to release the Company and BioReference from any civil or administrative monetarily liability arising from the Covered Conduct. Upon payment of the Settlement Amount and the amount due under a separate agreement with the Relator, the Relator has agreed to release the Company and BioReference from any and all claims and potential claims. Further, in consideration of the obligations of the Company and BioReference in the Settlement Agreement and the CIA, the OIG-HHS has agreed to release and refrain from instituting any administrative action seeking to exclude the Company or BioReference from participating in Medicare, Medicaid or other Federal health care programs as a result of the Covered Conduct.

Under the CIA, which has a term of 5 years, BioReference is required to, among other things: (i) maintain a Compliance Officer, a Compliance Committee, board review and oversight of certain federal healthcare compliance matters, compliance programs, and disclosure programs; (ii) provide management certifications and compliance training and education; (iii) establish written compliance policies and procedures to meet federal health care program requirements; (iv) create procedures designed to ensure compliance with the Anti-Kickback Statute and/or Stark Law; (v) engage an independent review organization to conduct a thorough review of BioReference’ s systems, policies, processes and procedures related to certain arrangements; (vi) implement a risk assessment and internal review process; (vii) establish a disclosure program for whistleblowers; and (viii) report or disclose certain events and physician payments. The Company’s or BioReference’s failure to comply with its obligations under the CIA could result in monetary penalties and the exclusion from participation in Federal Health Care Programs. The CIA does not apply to any of the Company’s subsidiaries other than BioReference, and its scope is generally limited to “focus arrangements”, which are those “arrangements” (as defined in the CIA) (i) between BioReference and any actual source or recipient of health care business or referrals and involves, directly or indirectly, the offer, payment, or provision of anything of value, or (ii) is between BioReference and any physician (or a physician’s immediate family member). Most of these measures have already been implemented at BioReference. Following its acquisition of BioReference, the Company and BioReference implemented robust compliance measures that substantially align with those actions required under the CIA.

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ITEM 2. MANAGEMENT’S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION AND RESULTS OF OPERATIONS.

OVERVIEW

You should read this discussion together with the unaudited Condensed Consolidated Financial Statements, related notes, and other financial information included elsewhere in this Quarterly Report on Form 10-Q together with our audited consolidated financial statements, related notes, and other information contained in our Annual Report on Form 10-K for the year ended December 31, 2021 (the “Form 10-K”). The following discussion contains assumptions, estimates and other forward-looking statements that involve a number of risks and uncertainties, including those discussed under “Risk Factors,” in Part I, Item 1A of the Form 10-K and as described from time to time in our other filings with the Securities and Exchange Commission. These risks could cause our actual results to differ materially from those anticipated in these forward-looking statements.

We are a diversified healthcare company that seeks to establish industry-leading positions in large and rapidly growing medical markets. Our diagnostics business includes BioReference Health LLC, formerly BioReference Laboratories, Inc. (“BioReference”), one of the nation’s largest full service laboratories with an almost 250-person sales and marketing team to drive growth and leverage new products. Our pharmaceutical business features Rayaldee, a U.S. Food and Drug Administration (“FDA”) approved treatment for secondary hyperparathyroidism (“SHPT”) in adults with stage 3 or 4 chronic kidney disease (“CKD”) and vitamin D insufficiency and a pipeline of products in various stages of development. Our leading product in development is Somatrogon (hGH-CTP), a once-weekly human growth hormone for which we have partnered with Pfizer, Inc. (“Pfizer”) and successfully completed a phase 3 study in August 2019. Regulatory applications for Somatrogon (hGH-CTP) have been submitted to several countries around the world for review. In February 2022, the European Commission granted marketing authorization in the European Union for Somatrogon (hGH-CTP) under the brand name NGENLA® to treat children and adolescents from as young as three years of age with growth disturbance due to insufficient secretion of growth hormone and we received pricing approval in Germany in April 2022. In January 2022, the Ministry of Health, Labour and Welfare in Japan approved NGENLA® (Somatrogon) for the long-term treatment of pediatric patients who have growth failure due to an inadequate secretion of endogenous growth hormone and we received pricing approval in April 2022. In October 2021, Health Canada approved NGENLA® for the long-term treatment of pediatric patients who have growth hormone deficiency, and Australia’s Therapeutic Goods Administration approved NGENLA® for the long-term treatment of pediatric patients with growth disturbance due to insufficient secretion of growth hormone. Pfizer also submitted the initial Biologics License Application (“BLA”) with the FDA for approval of Somatrogon (hGH-CTP) in the United States, and received a Complete Response Letter in January 2022. Pfizer and OPKO are evaluating the FDA’s comments and will work with the agency to determine the best path forward for Somatrogon (hGH-CTP) in the United States. We are incorporated in Delaware, and our principal executive offices are located in leased offices in Miami, Florida.

Through BioReference, we provide laboratory testing services, primarily to customers in the larger metropolitan areas in New York, New Jersey, Florida, Texas, Maryland, California, Pennsylvania, Delaware, Washington, DC, Illinois and Massachusetts, as well as to customers in a number of other states. We offer a comprehensive test menu of clinical diagnostics for blood, urine and tissue analysis. This includes hematology, clinical chemistry, immunoassay, infectious diseases, serology, hormones, and toxicology assays, as well as Pap smear, anatomic pathology (biopsies) and other types of tissue analysis. We market our laboratory testing services directly to physicians, geneticists, hospitals, clinics, correctional and other health facilities.

We operate established pharmaceutical platforms in Ireland, Chile, Spain, and Mexico, which are generating revenue and from which we expect to generate positive cash flow and facilitate future market entry for our products currently in development. In addition, we have a development and commercial supply pharmaceutical company and a global supply chain operation and holding company in Ireland. We own a specialty active pharmaceutical ingredients manufacturer in Israel, which we expect will facilitate the development of our pipeline of molecules and compounds for our proprietary molecular diagnostic and therapeutic products.

RECENT DEVELOPMENTS

In early 2022, each of the European Commission and the Ministry of Health, Labour and Welfare in Japan approved the next-generation long-acting recombinant human growth hormone NGENLA (Somatrogon), a once-weekly injection to treat pediatric growth hormone deficiency in Europe and Japan, respectively. Further, Canada and Australia approved NGENLA in October and November of 2021, respectively. In April 2022, Pfizer notified OPKO that NGENLA has received pricing approval in Germany and Japan. With the achievement of these milestones, we received $85.0 million in milestone payments during the second quarter of 2022.

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On April 29, 2022, the Company consummated the GeneDx Transaction, pursuant to which Sema4 acquired the Company’s former subsidiary, GeneDx. Sema4 paid to the Company aggregate consideration of $150.0 million in cash (before deduction of transaction expenses and other customary purchase price adjustments), together with 80.0 million shares (the “Closing Shares”) of Sema4’s Class A common stock, par value $0.0001 per share (“Sema4 Common Stock”). Additionally, Sema4 has agreed to pay the Company up to an additional $150.0 million, which may be paid in Sema4 Common Stock, cash or a combination thereof in Sema4’s discretion, subject to GeneDx achieving certain revenue targets for the fiscal years ending December 31, 2022 and 2023. GeneDx was formerly part of our diagnostics segment.

On May 9, 2022 (the “Closing Date”), the Company entered into the ModeX Merger Agreement with Merger Sub, ModeX and Gary J. Nabel, solely in his capacity as sellers’ representative, pursuant to which ModeX survived the ModeX Merger as a wholly owned subsidiary of the Company. ModeX is a biotechnology company focused on developing innovative multi-specific immune therapies for cancer and infections diseases and is part of our pharmaceutical segment. The Company paid the entirety of the $300.0 million purchase price pursuant to the issuance of the Consideration Shares of the Company’s Common Stock to the former stockholders of ModeX. The Consideration Shares were valued at $219.4 million, based on the closing price per share of our Common Stock of $2.44 as reported by NASDAQ on the Closing Date. Included in the total purchase price of $221.7 million are $2.3 million of fully vested equity awards.

The following table summarizes the preliminary purchase price allocation and the estimated fair value of the net assets acquired and liabilities assumed on the Closing Date. The purchase price allocation for ModeX is preliminary pending completion of the fair value analysis of acquired assets and liabilities:

(in thousands)	ModeX
Current assets
Cash and cash equivalents	$	218
Other assets	554
Property, plant and equipment	1,046
IPR&D assets	195,000
Goodwill	65,786
Accounts payable	(202)
Deferred tax liability	(40,740)
Total purchase price	$	221,662

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RESULTS OF OPERATIONS

Impact of COVID-19

We continue to be a part of the coordinated public and private sector response to SARS-CoV-2, a novel strain of coronavirus, referred to as COVID-19. There continues to be a high level of uncertainty relating to how the pandemic will evolve, how governments and consumers will react, progress on the distribution of vaccines and whether the pandemic will have a longer-term effect on the healthcare industry and patient habits. BioReference is providing COVID-19 solutions, including diagnostic molecular testing and serology antibody testing, to meet the testing needs of its customers, including physicians, health systems, long-term care facilities, governments, schools, employers, professional sports teams and entertainment venues, as well as the general public through relationships with retail pharmacy chains.

Since the pandemic began in the U.S., we have invested in testing capabilities and infrastructure to meet demand for our molecular and antibody testing for COVID-19. Throughout the pandemic, we have managed our company-wide lab operations specimen acquisition, logistics, procurement, customer service, and initiatives to manage our cost structure to match the ever changing COVID-19 testing volumes and to manage efficiency gains in our core clinical lines of business. We anticipate that COVID-19 will continue to impact our business in 2022 and, overall, we expect COVID-19 test demand to continue to decline in 2022 as compared to 2021.

Revenue from services for the six months ended June 30, 2022 decreased by $430.7 million as compared to 2021 due to lower COVID-19 testing volumes. Excluding COVID-19 test volumes, for the six months ended June 30, 2022, routine clinical test volume decreased 26.2% as compared to volumes for the six months ended June 30, 2021.

In March 2022, the U.S. Health Resources and Services Administration (“HRSA”) informed providers that, after March 22, 2022, it would stop accepting claims for testing and treatment for uninsured individuals under the HRSA COVID-19 Uninsured Program and that claims submitted prior to that date would be subject to eligibility and availability of funds. For the six months ended June 30, 2022, revenue for testing of uninsured individuals under the HRSA COVID-19 Uninsured Program represented approximately 5.7% of our COVID-19 testing revenue. As of June 30, 2022, less than 2% of our net accounts receivable was associated with claims for reimbursement for COVID-19 testing of uninsured individuals. Although we believe that our estimates for contractual allowances and patient price concessions are appropriate, actual results could differ from those estimates.

FOR THE THREE MONTHS ENDED JUNE 30, 2022 AND 2021

Our consolidated income (loss) from operations for the three months ended June 30, 2022 and 2021 was as follows:

	For the three months ended June 30,
(In thousands)	2022		2021		Change		% Change
Revenues:
Revenue from services	$	186,804	$	397,197	$	(210,393)	(53)	%
Revenue from products	35,892		35,663		229		1	%
Revenue from transfer of intellectual property and other	87,197		9,548		77,649		813	%
Total revenues	309,893		442,408		(132,515)		(30)	%
Costs and expenses:
Cost of revenue	194,311		292,908		(98,597)		(34)	%
Selling, general and administrative	101,464		113,236		(11,772)		(10)	%
Research and development	17,254		18,222		(968)		(5)	%
Contingent Consideration	175		(103)		278		(270)	%
Amortization of intangible assets	22,793		12,574		10,219		81	%
Gain on sale of assets	(15,365)		—		(15,365)		(100)	%
Total costs and expenses	320,632		436,837		(116,205)		(27)	%
Income (loss) from operations	(10,739)		5,571		(16,310)		(293)	%

Diagnostics

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	For the three months ended June 30,
(In thousands)	2022		2021		Change		% Change
Revenues
Revenue from services	$	186,804	$	397,197	$	(210,393)	(53)	%
Total revenues	186,804		397,197		(210,393)		(53)	%
Costs and expenses:
Cost of revenue	171,841		267,806		(95,965)		(36)	%
Selling, general and administrative	78,980		87,809		(8,829)		(10)	%
Research and development	2,780		4,023		(1,243)		(31)	%
Amortization of intangible assets	6,111		7,559		(1,448)		(19)	%
Gain of sale of assets	(15,365)		—		(15,365)		(100)	%
Total costs and expenses	244,347		367,197		(122,850)		(33)	%
Income (loss) from operations	(57,543)		30,000		(87,543)		(292)	%

Revenue. Revenue from services for the three months ended June 30, 2022 decreased by approximately $210.4 million compared to the three months ended June 30, 2021. The decrease in revenue for the three months ended June 30, 2022 reflects lower demand for COVID-19 testing and lower COVID-19 reimbursement of $162.5 million and $24.3 million, respectively. BioReference performed 0.9 million molecular tests for COVID-19 and 0.1 million serology antibody tests during the three months ended June 30, 2022, which represented 30.7% of total volume for that period. In comparison, the three months ended June 30, 2021 included 2.8 million molecular tests for COVID-19 and 0.2 million serology antibody tests. The reduction in reimbursement reflects an increase in utilization of antigen point of care diagnostic tests as well as a change in the mix of customers which have varying contract prices depending on the level of services we provide.

Clinical test reimbursement increased $4.5 million as a result of the mix of testing ordered. Partially offsetting the increase in clinical reimbursement was a decrease in clinical test volume of $10.9 million. Furthermore, as a result of the GeneDx Transaction during April 2022, genomic test revenues decreased by $17.2 million.

Estimated collection amounts are subject to the complexities and ambiguities of billing, reimbursement regulations and claims processing, as well as considerations unique to Medicare and Medicaid programs, and require us to consider the potential for retroactive adjustments when estimating variable consideration in the recognition of revenue in the period the related services are rendered. For the three months ended June 30, 2022, negative revenue adjustments due to changes in estimates of implicit price concessions for performance obligations satisfied in prior periods of $23.2 million were recognized. Revenue adjustments for the three months ended June 30, 2022 were primarily due to lower COVID-19 test reimbursement estimates. For the three months ended June 30, 2021, positive revenue adjustments due to changes in estimates of implicit price concessions for performance obligations satisfied in prior periods of $0.5 million were recognized. Revenue adjustments for the three months ended June 30, 2022 were primarily due to an increase improvement in COVID-19 test reimbursement estimates.

The composition of revenue from services by payor for the three months ended June 30, 2022 and 2021 was as follows:

	Three months ended June 30,
(In thousands)	2022		2021
Healthcare insurers	$	76,442	$	109,084
Government payers	25,659		57,611
Client payers	80,931		225,936
Patients	3,772		4,566
Total	$	186,804	$	397,197

Client payors include cities, states and companies for which BioReference provides COVID-19 testing services.

Cost of revenue. Cost of revenue for the three months ended June 30, 2022 decreased $96.0 million compared to the three months ended June 30, 2021. Cost of revenue decreased primarily due to a decline in the volume of COVID-19 tests performed during the three months ended June 30, 2022 compared to 2021. Cost of revenue for the three months ended June 30, 2022 also decreased due to changes in the test mix during the period. Cost of revenue also decreased by $13.9 million as a result of the GeneDx Transaction in April 2022.

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Selling, general and administrative expenses. Selling, general and administrative expenses for the three months ended June 30, 2022 and 2021 were $79.0 million and $87.8 million, respectively. Selling, general and administrative expenses in our diagnostics segment decreased primarily due to the GeneDx Transaction, which was partially offset by increases in our investment in our commercial digital organization resulting in higher professional fees, and personnel expenses. During the three months ended June 30, 2022, and continuing into July 2022, we have worked to revise BioReference’s strategic focus areas and limit the continuing investment in our commercial and digital health areas to align with our smaller base of operations.

Research and development expenses. The following table summarizes the components of our research and development expenses:

Research and Development Expenses	Three months ended June 30,
	2022		2021
External expenses:
PMA studies	$	—	$	31
Research and development employee-related expenses	2,233		2,742
Other internal research and development expenses	547		1,250
Total research and development expenses	$	2,780	$	4,023

The decrease in research and development expenses for the three months ended June 30, 2022 resulted primarily related to the development of clinical services at BioReference and as a result of the GeneDx Transaction.

Amortization of intangible assets. Amortization of intangible assets was $6.1 million and $7.6 million, respectively, for the three months ended June 30, 2022 and 2021. Amortization expense reflects the amortization of acquired intangible assets with defined useful lives. Amortization expense declined during the three months ended June 30, 2022 due to the GeneDx Transaction in April 2022 and due to acquired intangible assets becoming fully amortized.

Gain on sale of assets. Gain on sale of assets was $15.4 million for the three months ended June 30, 2022 due to the GeneDx Transaction in April 2022.

Pharmaceuticals

	For the three months ended June 30,
(In thousands)	2022		2021		Change		% Change
Revenues:
Revenue from products	$	35,892	$	35,663	$	229	1	%
Revenue from transfer of intellectual property and other	87,197		9,548		77,649		813	%
Total revenues	123,089		45,211		77,878		172	%
Costs and expenses:
Cost of revenue	22,470		25,111		(2,641)		(11)	%
Selling, general and administrative	13,518		14,120		(602)		(4)	%
Research and development	14,809		14,778		31		—	%
Contingent Consideration	175		(103)		278		(270)	%
Amortization of intangible assets	16,682		5,015		11,667		233	%
Total costs and expenses	67,654		58,921		8,733		15	%
Income (loss) from operations	55,435		(13,710)		69,145		(504)	%

Revenue. The increase in revenue from products for the three months ended June 30, 2022 compared to the three months ended June 30, 2021 was primarily attributable to an increase in sales of Rayaldee, which was partially offset by a decrease in

52

sales at OPKO Chile primarily due to foreign exchange fluctuations. Revenue from sales of Rayaldee for the three months ended June 30, 2022 and 2021 was $6.2 million and $5.0 million, respectively. Revenue from transfer of intellectual property and other for the three months ended June 30, 2022 reflects $85.0 million of milestone payments from Pfizer in the second quarter of 2022 due to the commencement of sales of NGENLA in Europe and Japan. Revenue from transfer of intellectual property for the three months ended June 30, 2021 includes a $5.0 million non-refundable upfront payment under the license agreement with Nicoya Therapeutics.

Cost of revenue. Cost of revenue for the three months ended June 30, 2022 decreased $2.6 million compared to the three months ended June 30, 2021 primarily due to due to changes in product mix during the period, foreign exchange fluctuations at our international operating companies and lower Rayaldee costs per unit.

Selling, general and administrative expenses. Selling, general and administrative expenses for the three months ended June 30, 2022 and 2021 were $13.5 million and $14.1 million, respectively. The decrease in selling, general and administrative expenses was primarily due to a decrease in employee-related expenses from Rayaldee. Selling, general and administrative expenses for the pharmaceutical segment for the three months ended June 30, 2022 and 2021 included equity-based compensation expense of $0.3 million and $0.4 million, respectively.

Research and development expenses. Research and development expenses for the three months ended June 30, 2022 and 2021 were $14.8 million and $14.8 million, respectively. Research and development expenses include external and internal expenses, partially offset by third-party grants and funding arising from collaboration agreements. External expenses include clinical and non-clinical activities performed by contract research organizations, lab services, purchases of drug and diagnostic product materials and manufacturing development costs. We track external research and development expenses by individual program for phase 3 clinical trials for drug approval and premarket approval for diagnostics tests, if any. Internal expenses include employee-related expenses such as salaries, benefits and equity-based compensation expense. Other internal research and development expenses are incurred to support overall research and development activities and include expenses related to general overhead and facilities.

The following table summarizes the components of our research and development expenses:

Research and Development Expenses	Three months ended June 30,
	2022		2021
External expenses:
Manufacturing expense for biological products	$	2,070	$	912
Phase III studies	2,200		2,660
Post-marketing studies	—		22
Earlier-stage programs	3,113		4,841
Research and development employee-related expenses	6,774		4,927
Other internal research and development expenses	652		1,430
Third-party grants and funding from collaboration agreements	—		(14)
Total research and development expenses	$	14,809	$	14,778

The increase in research and development expenses for the three months ended June 30, 2022 was primarily due to higher employee related-expenses as a result of our ModeX acquisition and its related development programs as well as higher CMC costs on Somatrogon (hGH-CTP) . Ongoing expenses on the Somatrogon (hGH-CTP) program support open label extension studies that will continue until market launch of Somatrogon (hGH-CTP) in certain countries, as well as the preparation of applications for marketing approvals. Research and development expenses for the pharmaceutical segment for the three months ended June 30, 2022 and 2021 included equity-based compensation expense of $0.6 million and $0.3 million, respectively.

Contingent consideration. Contingent consideration for the three months ended June 30, 2022 and 2021 was $0.2 million of expense and $0.1 million reversal of expense, respectively. Contingent consideration for the three months ended June 30, 2022 and 2021 was primarily attributable to changes in assumptions regarding the timing of achievement of future milestones for OPKO Renal, and potential amounts payable to former stockholders of OPKO Renal in connection therewith, pursuant to our acquisition agreement in March 2013.

Amortization of intangible assets. Amortization of intangible assets was $16.7 million and $5.0 million, respectively, for the three months ended June 30, 2022 and 2021. Amortization expense reflects the amortization of acquired intangible assets with defined useful lives. In the first quarter of 2022, we reclassified $590.2 million of IPR&D related to Somatrogon (hGH-CTP) from IPR&D in our Condensed Consolidated Balance Sheet upon the approval of NGENLA (Somatrogon) in Europe and Japan. The assets will be amortized on a straight-line basis over their estimated useful life of approximately 12 years.

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Corporate

	For the three months ended June 30,
(In thousands)	2022		2021		Change		% Change
Costs and expenses:
Cost of revenue	$	—	$	(9)	$	9	(100)	%
Selling, general and administrative	8,966		11,307		(2,341)		(21)	%
Research and development	(335)		(579)		244		(42)	%
Total costs and expenses	8,631		10,719		(2,088)		(19)	%
Loss from operations	(8,631)		(10,719)		2,088		(19)	%

Operating loss for our unallocated corporate operations for the three months ended June 30, 2022 and 2021 was $8.6 million and $10.7 million, respectively, and principally reflect general and administrative expenses incurred in connection with our corporate operations. The decrease in operating loss for our unallocated corporate operations for the three months ended June 30, 2022 was due to a decrease in professional fees incurred.

Other

Interest income. Interest income for the three months ended June 30, 2022 and 2021 was not significant as our cash investment strategy emphasizes the security of the principal invested and fulfillment of liquidity needs.

Interest expense. Interest expense for the three months ended June 30, 2022 and 2021 was $3.1 million and $4.9 million, respectively. Interest expense was principally related to interest incurred on the 2025 Notes, the 2023 Convertible Notes, the 2033 Senior Notes, and BioReference’s outstanding debt under the Credit Agreement. The decrease in interest expense was primarily due to the impact of the adoption of ASU 2020-06 on the 2025 Notes. Due to the adoption of ASU 2020-06, interest expense decreased due to the elimination of the discount created by recognizing a component of convertible debt in equity. Refer to Note 7.

Fair value changes of derivative instruments, net. Fair value changes of derivative instruments, net for the three months ended June 30, 2022 and 2021, was $0.3 million reversal of expense and $0.3 million of expense, respectively. Derivative expense for the three months ended June 30, 2022 and 2021 was principally related to the change in fair value on foreign currency forward exchange contracts at OPKO Chile.

Other income (expense), net. Other income (expense), net for the three months ended June 30, 2022 and 2021 was $73.0 million and $(11.8) million, respectively. Other income (expense), net for the three months ended June 30, 2022, includes $71.2 million of expense due to the decrease in the fair value of our Sema4 investment. Other expense for the three months ended June 30, 2021 primarily consisted of a $11.1 million non-cash loss related to the exchange of $55.4 million in outstanding 2025 Notes.

Income tax benefit (provision). Our income tax benefit (provision) for the three months ended June 30, 2022 and 2021 was $(15.1) million and $(4.8) million, respectively, and reflects quarterly results using our expected effective tax rate.  For the three months ended June 30, 2022, the tax rate differed from the U.S. federal statutory rate of 21% primarily due the relative mix in earnings and losses in the U.S. versus foreign tax jurisdictions, and operating results in tax jurisdictions which do not result in a tax benefit.

Loss from investments in investees. We have made investments in certain early stage companies that we perceive to have valuable proprietary technology and significant potential to create value for us as a shareholder or member. We account for these investments under the equity method of accounting, resulting in the recording of our proportionate share of their losses until our share of their loss exceeds our investment. Until the investees’ technologies are commercialized, if ever, we anticipate they will report net losses. Loss from investments in investees was $268 thousand and $67 thousand for the three months ended June 30, 2022 and 2021, respectively.

FOR THE SIX MONTHS ENDED JUNE 30, 2022 AND 2021

Our consolidated income (loss) from operations for the six months ended June 30, 2022 and 2021 is as follows:

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	For the six months ended June 30,
(In thousands)	2022		2021		Change		% Change
Revenues:
Revenue from services	$	473,402	$	904,149	$	(430,747)	(48)	%
Revenue from products	72,550		69,608		2,942		4	%
Revenue from transfer of intellectual property and other	93,159		13,816		79,343		574	%
Total revenues	639,111		987,573		(348,462)		(35)	%
Costs and expenses:
Cost of revenue	438,187		656,414		(218,227)		(33)	%
Selling, general and administrative	219,000		225,522		(6,522)		(3)	%
Research and development	35,566		37,537		(1,971)		(5)	%
Contingent Consideration	69		(1,059)		1,128		(107)	%
Amortization of intangible assets	44,818		25,151		19,667		78	%
Gain of sale of assets	(15,365)		—		(15,365)		(100)	%
Total costs and expenses	722,275		943,565		(221,290)		(23)	%
Income (loss) from operations	(83,164)		44,008		(127,172)		(289)	%

Diagnostics

	For the six months ended June 30,
(In thousands)	2022		2021		Change		% Change
Revenues
Revenue from services	$	473,402	$	904,149	$	(430,747)	(48)	%
Revenue from transfer of intellectual property and other	—		—		—		—	%
Total revenues	473,402		904,149		(430,747)		(48)	%
Costs and expenses:
Cost of revenue	393,048		607,233		(214,185)		(35)	%
Selling, general and administrative	173,936		177,127		(3,191)		(2)	%
Research and development	9,002		7,654		1,348		18	%
Amortization of intangible assets	13,873		15,121		(1,248)		(8)	%
Gain of sale of assets	(15,365)		—		(15,365)		(100)	%
Total costs and expenses	574,494		807,135		(232,641)		(29)	%
Income (loss) from operations	(101,092)		97,014		(198,106)		(204)	%

Revenue. Revenue from services for the six months ended June 30, 2022 decreased by approximately $430.7 million compared to the six months ended June 30, 2021. The decrease in revenue for the six months ended June 30, 2022 reflects lower demand for COVID-19 testing and lower COVID-19 reimbursement of $326.5 million and $50.8 million, respectively. BioReference performed 2.9 million molecular tests for COVID-19 and 0.2 million serology antibody tests during the six months ended June 30, 2022, which represented 41.7% of total volume for that period. In comparison, the six months ended June 30, 2021 included 6.9 million molecular tests for COVID-19 and 0.4 million serology antibody tests. The reduction in reimbursement reflects an increase in utilization of antigen point of care diagnostic tests as well as a change in the mix of customers which have varying contract prices depending on the level of services we provide.

For the six months ended June 30, 2022, clinical test volume and clinical test reimbursement decreased $9.0 million and $40.2 million, respectively, as a result of the mix of testing ordered. Furthermore, as a result of the GeneDx Transaction in April 2022, genomic test revenues decreased by $4.2 million.

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Estimated collection amounts are subject to the complexities and ambiguities of billing, reimbursement regulations and claims processing, as well as considerations unique to Medicare and Medicaid programs, and require us to consider the potential for retroactive adjustments when estimating variable consideration in the recognition of revenue in the period the related services are rendered. For the six months ended June 30, 2022, negative revenue adjustments due to changes in estimates of implicit price concessions for performance obligations satisfied in prior periods of $21.2 million were recognized. Revenue adjustments for the six months ended June 30, 2022 were primarily due to lower COVID-19 test reimbursement estimates. For the six months ended June 30, 2021, positive revenue adjustments due to changes in estimates of implicit price concessions for performance obligations satisfied in prior periods of $28.5 million were recognized. Revenue adjustments for the six months ended June 30, 2021 were primarily due to an increase in COVID-19 test reimbursement estimates.

The composition of Revenue from services by payor for the six months ended June 30, 2022 and 2021 was as follows:

	Six months ended June 30,
(In thousands)	2022		2021
Healthcare insurers	$	172,269	$	273,913
Government payers	53,263		131,269
Client payers	240,021		488,845
Patients	7,849		10,122
Total	$	473,402	$	904,149

Client payors include cities, states and companies for which BioReference provides COVID-19 testing services.

Cost of revenue. Cost of revenue for the six months ended June 30, 2022 decreased $214.2 million compared to the six months ended June 30, 2021. Cost of revenue decreased primarily due to a decline in the volume of COVID-19 tests performed during the six months ended June 30, 2022 compared to 2021. Cost of revenue for the six months ended June 30, 2022 also decreased due to changes in the test mix during the period. Cost of revenue also decreased by $11.4 million as a result of the GeneDx Transaction in April 2022.

Selling, general and administrative expenses. Selling, general and administrative expenses for the six months ended June 30, 2022 and 2021 were $173.9 million and $177.1 million, respectively. Selling, general and administrative expenses in our diagnostics segment decreased primarily due to revising BioReference’s strategic focus areas and limiting the continuing investment in our commercial and digital health areas to align with our smaller base of operations, as well as decreased expenses due to the GeneDx Transaction during the second quarter of 2022.

Research and development expenses. The following table summarizes the components of our research and development expenses:

Research and Development Expenses	Six months ended June 30,
	2022		2021
External expenses:
PMA studies	$	—	$	31
Research and development employee-related expenses	7,159		4,936
Other internal research and development expenses	1,843		2,687
Total research and development expenses	$	9,002	$	7,654

The increase in research and development expenses for the six months ended June 30, 2022 resulted primarily related to the development of clinical and genomics testing services at BioReference.

Amortization of intangible assets. Amortization of intangible assets was $13.9 million and $15.1 million, respectively, for the six months ended June 30, 2022 and 2021. Amortization expense reflects the amortization of acquired intangible assets with defined useful lives. Amortization expense declined during the six months ended June 30, 2022 due to the GeneDx Transaction in April 2022 and due to acquired intangible assets becoming fully amortized.

Gain on sale of assets. Gain on sale of assets for the six months ended June 30, 2022, was $15.4 million due to the sale of GeneDx Transaction in April 2022.

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Pharmaceuticals

	For the six months ended June 30,
(In thousands)	2022		2021		Change		% Change
Revenues:
Revenue from products	$	72,550	$	69,608	$	2,942	4	%
Revenue from transfer of intellectual property and other	93,159		13,816		79,343		574	%
Total revenues	165,709		83,424		82,285		99	%
Costs and expenses:
Cost of revenue	45,139		49,201		(4,062)		(8)	%
Selling, general and administrative	25,129		27,525		(2,396)		(9)	%
Research and development	27,100		30,595		(3,495)		(11)	%
Contingent Consideration	69		(1,059)		1,128		(107)	%
Amortization of intangible assets	30,945		10,030		20,915		209	%
Total costs and expenses	128,382		116,292		12,090		10	%
loss from operations	37,327		(32,868)		70,195		(214)	%

Revenue. The increase in revenue from products for the six months ended June 30, 2022 compared to the six months ended June 30, 2021 was primarily attributable to an increase in sales of Rayaldee, which was partially offset by a decrease in sales at OPKO Chile primarily due to foreign exchange fluctuations. Revenue from sales of Rayaldee for the six months ended June 30, 2022 and 2021 was $11.3 million and $10.8 million, respectively. Revenue from transfer of intellectual property and other for the six months ended June 30, 2022 reflect $85.0 million of milestone payments from Pfizer in the second quarter of 2022 due to the commencement of sales of NGENLA in Europe and Japan. Revenue from transfer of intellectual property for the six months ended June 30, 2021 includes a $5.0 million non-refundable upfront payment under the license agreement with Nicoya Therapeutics.

Cost of revenue. Cost of revenue for the six months ended June 30, 2022 decreased $4.1 million compared to the six months ended June 30, 2021 primarily due to changes in the product mix during the period, foreign exchange fluctuations at our international operating companies and lower Rayaldee costs per unit in addition to a decrease in lower volume compared to the prior period . This was partially offset by a $2.7 million inventory reserve charge for Rayaldee recognized for the six months ended June 30, 2021.

Selling, general and administrative expenses. Selling, general and administrative expenses for the six months ended June 30, 2022 and 2021 were $25.1 million and $27.5 million, respectively. The decrease in selling, general and administrative expenses was primarily due to a decrease in legal expenses and selling expenses related to Rayaldee. Selling, general and administrative expenses for the pharmaceutical segment for the six months ended June 30, 2022 and 2021 included equity-based compensation expense of $0.7 million and $0.7 million, respectively.

Research and development expenses. Research and development expenses for the six months ended June 30, 2022 and 2021 were $27.1 million and $30.6 million, respectively. Research and development expenses include external and internal expenses, partially offset by third-party grants and funding arising from collaboration agreements. External expenses include clinical and non-clinical activities performed by contract research organizations, lab services, purchases of drug and diagnostic product materials and manufacturing development costs. We track external research and development expenses by individual program for phase 3 clinical trials for drug approval and premarket approval for diagnostics tests, if any. Internal expenses include employee-related expenses such as salaries, benefits and equity-based compensation expense. Other internal research and development expenses are incurred to support overall research and development activities and include expenses related to general overhead and facilities.

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The following table summarizes the components of our research and development expenses:

Research and Development Expenses	Six months ended June 30,
	2022		2021
External expenses:
Manufacturing expense for biological products	$	3,319	$	2,479
Phase III studies	4,832		5,011
Post-marketing studies	12		27
Earlier-stage programs	5,714		10,034
Research and development employee-related expenses	11,953		10,255
Other internal research and development expenses	1,270		2,813
Third-party grants and funding from collaboration agreements	—		(24)
Total research and development expenses	$	27,100	$	30,595

The decrease in research and development expenses for the six months ended June 30, 2022 was primarily due to a decrease in research and development expenses for Somatrogon (hGH-CTP). Ongoing expenses on the Somatrogon (hGH-CTP) program support open label extension studies that will continue until market launch of Somatrogon (hGH-CTP) in certain countries, as well as the preparation of applications for marketing approvals. Partially offsetting the decrease in Somatrogon (hGH-CTP) spend are costs related to our ModeX acquisition and its related development programs. Research and development expenses for the pharmaceutical segment for the six months ended June 30, 2022 and 2021 included equity-based compensation expense of $0.9 million and $0.7 million, respectively.

Contingent consideration. Contingent consideration for the six months ended June 30, 2022 and 2021 was $0.1 million of expense and $1.1 million reversal of expense, respectively. Contingent consideration for the six months ended June 30, 2022 and 2021 was primarily attributable to changes in assumptions regarding the timing of achievement of future milestones for OPKO Renal, and potential amounts payable to former stockholders of OPKO Renal in connection therewith, pursuant to our acquisition agreement in March 2013.

Amortization of intangible assets. Amortization of intangible assets was $30.9 million and $10.0 million, respectively, for the six months ended June 30, 2022 and 2021. Amortization expense reflects the amortization of acquired intangible assets with defined useful lives. In the first quarter of 2022, we reclassified $590.2 million of IPR&D related to Somatrogon (hGH-CTP) from IPR&D in our Condensed Consolidated Balance Sheet upon the approval of NGENLA (Somatrogon) in Europe and Japan. The assets will be amortized on a straight-line basis over their estimated useful life of approximately 12 years.

Corporate

	For the six months ended June 30,
(In thousands)	2022		2021		Change		% Change
Costs and expenses:
Cost of revenue	$	—	$	(20)	$	20	(100)	%
Selling, general and administrative	19,935		20,870		(935)		(4)	%
Research and development	(536)		(712)		176		(25)	%
Total costs and expenses	19,399		20,138		(739)		(4)	%
Loss from operations	(19,399)		(20,138)		739		(4)	%

Operating loss for our unallocated corporate operations for the six months ended June 30, 2022 and 2021 was $19.4 million and $20.1 million, respectively, and principally reflect general and administrative expenses incurred in connection with our corporate operations. The decrease in operating loss for our unallocated corporate operations for the six months ended June 30, 2022 was driven by a decrease in legal and professional fees.

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Other

Interest income. Interest income for the six months ended June 30, 2022 and 2021 was not significant as our cash investment strategy emphasizes the security of the principal invested and fulfillment of liquidity needs.

Interest expense. Interest expense for the six months ended June 30, 2022 and 2021 was $5.7 million and $10.3 million, respectively. Interest expense was principally related to interest incurred on the 2025 Notes, the 2023 Convertible Notes, the 2033 Senior Notes, and BioReference’s outstanding debt under the Credit Agreement. The decrease in interest expense was primarily due to the impact of the adoption of ASU 2020-06 on the 2025 Notes. Due to the adoption of ASU 2020-06, interest expense decreased due to the elimination of the discount created by recognizing a component of convertible debt in equity. Refer to Note 7.

Fair value changes of derivative instruments, net. Fair value changes of derivative instruments, net for the six months ended June 30, 2022 and 2021, were $0.2 million reversal of expense and $0.7 million of expense, respectively. Derivative expense for the six months ended June 30, 2022 and 2021, was principally related to the change in fair value on foreign currency forward exchange contracts at OPKO Chile.

Other income (expense), net. Other income (expense), net for the six months ended June 30, 2022 and 2021, was $74.4 million and $12.7 million of expense, respectively. Other income (expense), net for the six months ended June 30, 2022, includes a $71.2 million of expense due to the decrease in the fair value of our Sema4 investment. Other expense for the six months ended June 30, 2021 primarily consisted of an $11.1 million non-cash loss related to the exchange of $55.4 million outstanding 2025 Notes. Furthermore, other income (expense) for the six months ended June 30, 2022 decreased from the comparable period due to foreign currency transaction gains (losses) recognized during the period.

Income tax benefit (provision). Our income tax benefit (provision) for the six months ended June 30, 2022 and 2021 was $6.2 million and $(5.3) million, respectively, and reflects quarterly results using our expected effective tax rate.  For the six months ended June 30, 2022, the tax rate differed from the U.S. federal statutory rate of 21% primarily due to a $22.0 million discrete benefit resulting from reduced tax rates that will be applicable to existing foreign deferred tax liabilities, as well as the relative mix in earnings and losses in the U.S. versus foreign tax jurisdictions, and operating results in tax jurisdictions which do not result in a tax benefit.

Loss from investments in investees. We have made investments in certain early stage companies that we perceive to have valuable proprietary technology and significant potential to create value for us as a shareholder or member. We account for these investments under the equity method of accounting, resulting in the recording of our proportionate share of their losses until our share of their loss exceeds our investment. Until the investees’ technologies are commercialized, if ever, we anticipate they will report net losses. Loss from investments in investees was $0.3 million and $0.1 million for the six months ended June 30, 2022 and 2021, respectively.

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LIQUIDITY AND CAPITAL RESOURCES

At June 30, 2022, we had cash and cash equivalents of approximately $210.5 million. Cash used in operations of $31.3 million for the six months ended June 30, 2022 principally reflects general and administrative expenses related to our corporate operations and research and development activities. Cash used in investing activities for the six months ended June 30, 2022 primarily reflects capital expenditures of $10.6 million. Cash provided by financing activities of $4.4 million primarily reflects net borrowings on our lines of credit. We have historically not generated sustained positive cash flow sufficient to offset our operating and other expenses, and our primary sources of cash have been from the public and private placement of equity, the issuance of the 2033 Senior Notes, 2023 Convertible Notes and 2025 Notes and credit facilities available to us.

On April 28, 2022, the Company consummated the GeneDx Transaction. Sema4 paid to the Company aggregate consideration of $150 million in cash (before deduction of transaction expenses and other customary purchase price adjustments), together with the Closing Shares. Additionally, Sema4 has agreed to pay the Company the Milestone Consideration, subject to GeneDx achieving certain revenue targets. Based on the closing stock price of Sema4 as of April 29, 2022, the total upfront consideration represents approximately $322 million, and the total aggregate consideration including the potential Milestone Consideration is approximately $447 million. We recognized a gain of $15.4 million on the GeneDx Transaction during the second quarter of 2022.

On May 9, 2022, the Company entered into the ModeX Merger Agreement with Merger Sub, ModeX and Gary J. Nabel, solely in his capacity as sellers’ representative, pursuant to which ModeX survived the ModeX Merger as a wholly owned subsidiary of the Company. The Company paid the entirety of the $300.0 million purchase price pursuant to the issuance of the Consideration Shares of the Company’s Common Stock to the former stockholders of ModeX. The Consideration Shares were valued at $219.4 million, based on the closing price per share of our Common Stock of $2.44 as reported by NASDAQ on the Closing Date.

In April 2022, Pfizer notified OPKO that NGENLA (Somatrogon), a once-weekly injection to treat pediatric growth hormone deficiency, has received pricing approval in Germany and Japan. NGENLA was granted marketing authorization by the Ministry of Health, Labour and Welfare in Japan and by the European Commission in January and February of this year, respectively. With the achievement of these milestones, we received $85.0 million in milestone payments during the second quarter of 2022.

In February 2019, we issued $200.0 million aggregate principal amount of the 2025 Notes in an underwritten public offering. The 2025 Notes bear interest at a rate of 4.50% per year, payable semiannually in arrears on February 15 and August 15 of each year. The notes mature on February 15, 2025, unless earlier repurchased, redeemed or converted.

Holders may convert their 2025 Notes into shares of Common Stock at their option at any time prior to the close of business on the business day immediately preceding November 15, 2024, subject to the satisfaction of certain conditions. Upon conversion, we will pay or deliver, as the case may be, cash, shares of our Common Stock, or a combination of cash and shares of our Common Stock, at our election.

The current conversion rate for the 2025 Notes is 236.7424 shares of Common Stock per $1,000 principal amount of 2025 Notes (equivalent to a conversion price of approximately $4.22 per share of Common Stock). The conversion rate for the 2025 Notes is subject to adjustment in certain events but will not be adjusted for any accrued and unpaid interest.

In May 2021, we entered into exchange agreements with certain holders of the 2025 Notes pursuant to which the holders exchanged $55.4 million in aggregate principal amount of the outstanding 2025 Notes for 19,051,270 shares of our Common Stock (the “Exchange”).

As of June 30, 2022, the total commitments under our Credit Agreement with CB and our lines of credit with financial institutions in Chile and Spain were $82.3 million, of which $18.2 million was drawn as of June 30, 2022. At June 30, 2022, the weighted average interest rate on these lines of credit was approximately 5.4%. These lines of credit are short-term and are used primarily as a source of working capital. The highest aggregate principal balance at any time outstanding during the six months ended June 30, 2022 was $20.5 million. We intend to continue to draw under these lines of credit as needed. There is no assurance that these lines of credit or other funding sources will be available to us on acceptable terms, or at all, in the future.

The Credit Agreement provides for a $75.0 million secured revolving credit facility and includes a $20.0 million sub-facility for swingline loans and a $20.0 million sub-facility for the issuance of letters of credit. The Credit Agreement matures on August 30, 2024 and is guaranteed by all of BioReference’s domestic subsidiaries, subject to certain exceptions. The Credit Agreement is also secured by substantially all assets of BioReference and its domestic subsidiaries, subject to certain exceptions, as well as a non-recourse pledge by us of our equity interest in BioReference. Availability under the Credit Agreement is based on a borrowing base composed of eligible accounts receivables of BioReference and certain of its

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subsidiaries, as specified therein. As of June 30, 2022, $53.1 million remained available for borrowing under the Credit Agreement.

In connection with our agreements with Pfizer, VFMCRP, Nicoya and CAMP4, we are eligible to receive various milestone payments and royalty considerations. Under the terms of the Pfizer Agreement, we are eligible to receive up to an additional $275.0 million upon the achievement of certain regulatory milestones, including $85 million of milestone payments we received during the second quarter of 2022. In addition, we are eligible to receive initial tiered royalty payments associated with the commercialization of Somatrogon for adult GHD with percentage rates ranging from the high teens to mid-twenties. Upon the launch of Somatrogon for pediatric GHD in certain major markets, the royalties will transition to regional, tiered gross profit sharing for both Somatrogon and Pfizer’s Genotropin®. Under the terms of the VFMCRP Agreement, we are entitled to receive up to an additional $17 million in regulatory milestones and $207 million in milestone payments tied to launch, pricing and sales of Rayaldee, including a $3.0 million milestone payment we recognized during the six months ended June 30, 2022 upon the first sale of Rayaldee in Europe. In addition, we are eligible to receive tiered, double-digit royalty payments. Under the terms of the Nicoya Agreement, we received an initial upfront payment of $5 million and are eligible to receive an additional $5 million upon the first to occur of (A) a predetermined milestone and (B) the first anniversary of the effective date. We are also eligible to receive up to an additional aggregate amount of $115 million upon the achievement of certain development, regulatory and sales-based milestones by Nicoya for the Nicoya Product in the Nicoya Territory. We will also receive tiered, double digit royalty payments at rates in the low double digits on net product sales within the Nicoya Territory and in the Nicoya Field. Under the terms of the CAMP4 Agreement, we received an initial upfront payment of $1.5 million and we are eligible to receive up to $3.5 million in development milestone payments for Dravet syndrome products, and $4 million for non-Dravet syndrome products, as well as sales milestones of up to $90 million for Dravet syndrome products and up to $90 million for non-Dravet syndrome products.

In connection with our acquisitions of CURNA, OPKO Diagnostics and OPKO Renal, we agreed to pay future consideration to the sellers upon the achievement of certain events, including up to an additional $19.1 million in shares of our Common Stock to the former stockholders of OPKO Diagnostics upon and subject to the achievement of certain milestones; and up to an additional $125.0 million in either shares of our Common Stock or cash, at our option subject to the achievement of certain milestones, to the former shareholders of OPKO Renal. As a result of our execution of the CAMP4 Agreement, we will have to pay a percentage of any payments received under the CAMP4 Agreement to the former CURNA stockholders.

We believe that the cash and cash equivalents on hand at June 30, 2022 and the amounts available to be borrowed under our lines of credit are sufficient to meet our anticipated cash requirements for operations and debt service beyond the next 12 months. We based this estimate on assumptions that may prove to be wrong or are subject to change, and we may be required to use our available cash resources sooner than we currently expect. If we acquire additional assets or companies, accelerate our product development programs or initiate additional clinical trials, we will need additional funds. Our future cash requirements, and the timing of those requirements, will depend on a number of factors, including the evolving impact of the COVID-19 pandemic on our business, the approval and success of our products in development, particularly our long acting Somatrogon for which we have received approval in Europe, Japan, Australia and Canada, submitted for approval in the U.S. and received a Complete Response Letter in January 2022, the approval and success of Somatrogon outside the United States, including in Europe, Japan, Australia and Canada, the commercial success of Rayaldee, including from the recent launch of Rayaldee by Vifor and in other territories expected in 2022, BioReference’s financial performance, possible acquisitions and dispositions, the continued progress of research and development of our product candidates, the timing and outcome of clinical trials and regulatory approvals, the costs involved in preparing, filing, prosecuting, maintaining, defending, and enforcing patent claims and other intellectual property rights, the status of competitive products, the availability of financing, our success in developing markets for our product candidates and results of government investigations, payor claims, and legal proceedings that may arise, including, without limitation class action and derivative litigation to which we are subject, and our ability to obtain insurance coverage for such claims. We have historically not generated sustained positive cash flow and if we are not able to secure additional funding when needed, we may have to delay, reduce the scope of, or eliminate one or more of our clinical trials or research and development programs or possible acquisitions or reduce our marketing or sales efforts or cease operations.

Additionally, the rapid development and fluidity of the COVID-19 pandemic and new variants of the virus makes it very difficult to predict its ultimate impact on our business, results of operations and liquidity. The pandemic presents a significant uncertainty that could materially and adversely affect our results of operations, financial condition and cash flows, including a negative impact on non-COVID-related diagnostics testing services provided by BioReference in our diagnostics segment. Further, deteriorating economic conditions globally as a result of the COVID-19 pandemic have in the past resulted, and may in the future result in a challenging capital raising environment, which could materially limit our access to capital, whether through the issuance and sale of our Common Stock, debt securities or otherwise, as well as through bank facilities and lines of credit. Events resulting from the effects of COVID-19 or new variants of the virus could negatively impact our ability to comply with certain covenants in the Credit Agreement or require that we pursue alternative financing. We can provide no

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assurance that any such alternative financing, if required, could be obtained on acceptable terms or at all. The combination of potential disruptions to our business resulting from COVID-19 together with and volatile credit and capital markets could adversely impact our future liquidity, which could have an adverse effect on our business and results of operations. We will continue to monitor and assess the impact COVID-19 and new variants of the virus may have on our business and financial results.

The following table provides information as of June 30, 2022, with respect to the amounts and timing of our known contractual obligation payments due by period.

Contractual obligations (In thousands)	Remaining six months ending December 31, 2022		2023		2024		2025		2026		Thereafter		Total
Open purchase orders	$	191,641	$	5,564	$	—	$	—	$	—	$	—	$	197,205
Operating leases	6,532		10,554		6,508		4,087		3,128		12,189		42,998
Finance leases	1,322		2,278		1,738		1,248		626		1		7,213
2033 Senior Notes, 2025 and 2023 Convertible Notes	—		69,939		—		141,537		—		—		211,476
Mortgages and other debts payable	1,391		814		472		255		—		—		2,932
Lines of credit	18,218		—		—		—		—		—		18,218
Interest commitments	4,844		6,955		6,528		571		—		—		18,898
Total	$	223,948	$	96,104	$	15,246	$	147,698	$	3,755	$	12,190	$	498,940

The preceding table does not include information where the amounts of the obligations are not currently determinable, including the following:

•Contractual obligations in connection with clinical trials, which span over two years, and that depend on patient enrollment. The total amount of expenditures is dependent on the actual number of patients enrolled and as such, the contracts do not specify the maximum amount we may owe.

•Product license agreements effective during the lesser of 15 years or patent expiration whereby payments and amounts are determined by applying a royalty rate on uncapped future sales.

•Contingent consideration that includes payments upon achievement of certain milestones including meeting development milestones such as the completion of successful clinical trials, NDA approvals by the FDA and revenue milestones upon the achievement of certain revenue targets all of which are anticipated to be paid within the next seven years and are payable in either shares of our Common Stock or cash, at our option, and that may aggregate up to $144.1 million.

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CRITICAL ACCOUNTING POLICIES AND ESTIMATES

There were no material changes to our critical accounting policies and estimates described in our Annual Report on Form 10-K for the fiscal year ended December 31, 2021 that have had a material impact on our Condensed Consolidated Financial Statements and related notes.

RECENT ACCOUNTING PRONOUNCEMENTS

Recently adopted accounting pronouncements.

In August 2020, the FASB issued ASU No. 2020-06, “Debt—Debt with Conversion and Other Options (Subtopic 470-20) and Derivatives and Hedging—Contracts in Entity's Own Equity (Subtopic 815-40).” ASU 2020-06 simplifies the accounting for convertible instruments by reducing the number of accounting models for convertible debt instruments and convertible preferred stock. The ASU is effective for public entities for fiscal years beginning after December 15, 2021, with early adoption permitted. As required, we adopted ASU 2020-06 on January 1, 2022 and used the modified retrospective approach for all convertible debt instruments at the beginning of the period of adoptions. Results for reporting periods beginning January 1, 2022 are presented under ASU 2020-06, while prior period amounts were not adjusted and continue to be reported in accordance historic accounting guidance.

Under the modified approach, entities will apply the guidance to all financial instruments that are outstanding as of the beginning of the year of adoption with the cumulative effect recognized as an adjustment to the opening balance of retained earnings. ASU 2020-06 eliminates the cash conversion and beneficial conversion feature models in ASC 470-20 that require an issuer of certain convertible debt and preferred stock to separately account for embedded conversion features as a component of equity. The adoption of ASU 2020-06 at January 1, 2022 resulted in an increase of the Convertible notes of $25.6 million, a reduction of the Accumulated deficit of $17.5 million and a reduction of Additional paid-in capital of $39.1 million.

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Item 3. Quantitative and Qualitative Disclosures About Market Risk

In the normal course of doing business, we are exposed to the risks associated with foreign currency exchange rates and changes in interest rates.

Foreign Currency Exchange Rate Risk – We operate globally and, as such, we are subject to foreign exchange risk in our commercial operations as portions of our revenues are exposed to changes in foreign currency exchange rates, primarily the Chilean Peso, the Mexican Peso, and the Euro.

Although we do not speculate in the foreign exchange market, we may from time to time manage exposures that arise in the normal course of business related to fluctuations in foreign currency exchange rates by entering into offsetting positions through the use of foreign exchange forward contracts. Certain firmly committed transactions may be hedged with foreign exchange forward contracts. As exchange rates change, gains and losses on the exposed transactions are partially offset by gains and losses related to the hedging contracts. Both the exposed transactions and the hedging contracts are translated and fair valued, respectively, at current spot rates, with gains and losses included in earnings.

Our derivative activities, which consist of foreign exchange forward contracts, are initiated to economically hedge forecasted cash flows that are exposed to foreign currency risk. The foreign exchange forward contracts generally require us to exchange local currencies for foreign currencies based on pre-established exchange rates at the contracts’ maturity dates. As exchange rates change, gains and losses on these contracts are generated based on the change in the exchange rates that are recognized in the Condensed Consolidated Statements of Operations and offset the impact of the change in exchange rates on the foreign currency cash flows that are hedged. If the counterparties to the exchange contracts do not fulfill their obligations to deliver the contracted currencies, we could be at risk for currency related fluctuations. Our foreign exchange forward contracts primarily hedge exchange rates on the Chilean Peso to the U.S. dollar. If Chilean Pesos were to strengthen or weaken in relation to the U.S. dollar, our loss or gain on hedged foreign currency cash-flows would be offset by the derivative contracts, with a net effect of zero.

We do not engage in trading market risk sensitive instruments or purchasing hedging instruments or “other than trading” instruments that are likely to expose us to significant market risk, whether interest rate, foreign currency exchange, commodity price, or equity price risk.

Interest Rate Risk – Our exposure to interest rate risk relates to our cash and investments and to our borrowings. We generally maintain an investment portfolio of money market funds and marketable securities. The securities in our investment portfolio are not leveraged, and are, due to their very short-term nature, subject to minimal interest rate risk. We currently do not hedge interest rate exposure. Because of the short-term maturities of our investments, we do not believe that a change in market interest rates would have a significant negative impact on the value of our investment portfolio except for reduced income in a low interest rate environment.

At June 30, 2022, we had cash and cash equivalents of $210.5 million. The weighted average interest rate related to our cash and cash equivalents for the six months ended June 30, 2022 was less than 1%. As of June 30, 2022, the principal outstanding balances under BioReference’s Credit Agreement with CB and our Chilean and Spanish lines of credit was $18.2 million in the aggregate at a weighted average interest rate of approximately 5.4%.

Our $3.0 million aggregate principal amount of our 2033 Senior Notes has a fixed interest rate of 3%, our $55.0 million aggregate principal amount of our 2023 Convertible Notes has a fixed interest rate of 5%, and our $200.0 million aggregate principal amount of the 2025 Notes has a fixed interest rate of 4.50%, and therefore are not subject to fluctuations in market interest rates.

The primary objective of our investment activities is to preserve principal while at the same time maximizing yields without significantly increasing risk. To achieve this objective, we may invest our excess cash in debt instruments of the U.S. Government and its agencies, bank obligations, repurchase agreements and high-quality corporate issuers, and money market funds that invest in such debt instruments, and, by policy, restrict our exposure to any single corporate issuer by imposing concentration limits. To minimize the exposure due to adverse shifts in interest rates, we maintain investments at an average maturity of generally less than three months.

64

Item 4. Controls and Procedures

Disclosure Controls and Procedures

Our management, with the participation of our Chief Executive Officer and our Chief Financial Officer, have evaluated the effectiveness of the Company’s disclosure controls and procedures (as defined in Rules 13a-15(e) and 15d-15(e) under the Exchange Act) as of the end of the period covered by this Quarterly Report on Form 10-Q. Our disclosure controls and procedures are designed to provide reasonable assurance that information required to be disclosed by us in the reports that we file or submit under the Exchange Act is recorded, processed, summarized and reported, within the time periods specified in the rules and forms of the Securities and Exchange Commission. Disclosure controls and procedures include, without limitation, controls and procedures designed to ensure that information required to be disclosed by a company in the reports that it files or submits under the Exchange Act is accumulated and communicated to the company’s management, including its principal executive and principal financial officers, as appropriate to allow timely decisions regarding required disclosure. Based on this evaluation, management concluded that our disclosure controls and procedures were effective as of June 30, 2022.

Changes to the Company’s Internal Control Over Financial Reporting

There have been no changes to the Company’s internal control over financial reporting that occurred during the quarter ended June 30, 2022 that have materially affected, or are reasonably likely to materially affect, the Company’s internal control over financial reporting.

65

PART II. OTHER INFORMATION

Item 1. Legal Proceedings

We are, from time to time, party to various legal proceedings arising out of our business. During the reporting period, covered by this Quarterly Report on Form 10-Q, there have been no material changes to the description of legal proceedings set forth in our Annual Report on Form 10-K for the year ended December 31, 2021 and in our Quarterly Report on Form 10-Q for the quarterly period ended March 31, 2022.

See Note 12 to the interim unaudited condensed consolidated financial statements contained in this Quarterly Report on Form 10-Q for information regarding the status of legal proceedings involving the Company, which information is incorporated by reference herein.

66

Item 1A. Risk Factors

Except as set forth in this Item 1A, there have been no material changes to our risk factors as previously disclosed in our Annual Report on Form 10-K for the year ended December 31, 2021.

If OPKO’s subsidiary, BioReference, fails to comply with the terms of its Corporate Integrity Agreement (“CIA”), it could be subjected to monetary penalties or the exclusion from participation in the Medicare Program, the Medicaid Program and the TRICARE Program (“Federal Health Care Programs”).

The Company and BioReference entered into a five-year CIA with the Office of Inspector General of the Department of Health and Human Services (“OIG-HHS”), effective as of July 14, 2022, concurrent with the execution of a settlement agreement with the United States, acting through the United States Department of Justice and on behalf of the OIG-HHS. The CIA imposes certain compliance, auditing (including by an independent review organization), self-reporting and training requirements with which BioReference must comply. If the Company fails to comply with the terms of the CIA, it could be subject to monetary penalties and/or exclusion from participation in Federal Health Care Programs. Any such suspension, exclusion or termination could result in the revocation or termination of contracts and/or licenses and potentially have a material adverse effect on the results of BioReference’s operations. The imposition of monetary penalties and/or termination of contracts with respect to BioReference could adversely affect the Company’s profitability and financial condition. The CIA does not apply to any of the Company’s subsidiaries other than BioReference, and its scope is generally limited to “focus arrangements”, which are those “arrangements” (as defined in the CIA) (i) between BioReference and any actual source or recipient of health care business or referrals and involves, directly or indirectly, the offer, payment, or provision of anything of value, or (ii) is between BioReference and any physician (or a physician’s immediate family member). Most of the compliance, auditing (including by an independent review organization), self-reporting and training requirements have already been implemented at BioReference.

Item 2. Unregistered Sales of Equity Securities and Use of Proceeds

None.

Item 3. Defaults Upon Senior Securities

None.

Item 4. Mine Safety Disclosures

Not Applicable.

Item 5. Other Information

None.

67

Item 6. Exhibits

Exhibit 2.1*	Agreement and Plan of Merger, dated as of May 9, 2022, by and among the Company, ModeX Therapeutics, Inc., Orca Acquisition Sub, Inc. and Gary J. Nabel, solely in the capacity of a representative of the stockholders (filed as Exhibit 2.1 to the Company’s Current Report on Form 8‑K filed with the SEC on May 13, 2022 and incorporated by reference herein).
Exhibit 10.1	Waiver Under and Amendment No. 1 to Amended and Restated Credit Agreement, dated as of April 29. 2022, by and among BioReference Health LLC, GeneDx, LLC, the other subsidiary borrowers and loan parties thereto, the Lenders party thereto and JPMorgan Chase Bank, N.A., as administrative agent (filed as Exhibit 10.1 to the Company’s current Report on Form 8-K filed with the SEC on May 4, 2022 and incorporated by reference herein).
Exhibit 10.2**	Lock-up and Voting Agreement, dated as of May 9, 2022, by and among the Company, Dr. Phillip Frost, Dr. Jane Hsiao and Frost Gamma Investments Trust (filed as Exhibit 10.1 to the Company’s Current Report on Form 8-K filed with the SEC on May 13, 2022 and incorporated by reference herein).
Exhibit 10.3**	Offer Letter, dated May 9, 2022, by and between the Company and Dr. Zerhouni (filed as Exhibit 10.2 to the Company’s Current Report on Form 8-K filed with the SEC on May 13, 2022 and incorporated by reference herein).
Exhibit 10.4**	Offer Letter, dated May 9, 2022, by and between the Company and Dr. Nabel (filed as Exhibit 10.3 to the Company’s Current Report on Form 8-K filed with the SEC on May 13, 2022 and incorporated by reference herein).
Exhibit 31.1	Certification by Phillip Frost, Chief Executive Officer, pursuant to Rule 13a-14(a) and 15d-14(a) of the Securities and Exchange Act of 1934 as adopted pursuant to Section 302 of the Sarbanes-Oxley Act of 2002 for the quarterly period ended June 30, 2022.
Exhibit 31.2	Certification by Adam Logal, Chief Financial Officer, pursuant to Rule 13a-14(a) and 15d-14(a) of the Securities and Exchange Act of 1934 as adopted pursuant to Section 302 of the Sarbanes-Oxley Act of 2002 for the quarterly period ended June 30, 2022.
Exhibit 32.1	Certification by Phillip Frost, Chief Executive Officer pursuant to 18 U.S.C. Section 1350, as adopted pursuant to Section 906 of the Sarbanes-Oxley Act of 2002 for the quarterly period ended June 30, 2022.
Exhibit 32.2	Certification by Adam Logal, Chief Financial Officer, pursuant to 18 U.S.C. Section 1350, as adopted pursuant to Section 906 of the Sarbanes-Oxley Act of 2002 for the quarterly period ended June 30, 2022.
Exhibit 101.INS	Inline XBRL Instance Document
Exhibit 101.SCH	Inline XBRL Taxonomy Extension Schema Document
Exhibit 101.CAL	Inline XBRL Taxonomy Extension Calculation Linkbase Document
Exhibit 101.DEF	Inline XBRL Taxonomy Extension Definition Linkbase Document
Exhibit 101.LAB	inline XBRL Taxonomy Extension Label Linkbase Document
Exhibit 101.PRE	Inline XBRL Taxonomy Extension Presentation Linkbase Document
Exhibit 104	Cover Page Interactive Data File (formatted as Inline XBRL and contained in Exhibit 101)

*    Pursuant to Item 601(a)(5) of Regulation S-K, schedules and similar attachments to this exhibit have been omitted because they do not contain information material to an investment or voting decision and such information is not otherwise disclosed in such exhibit. The Company will supplementally provide a copy of any omitted schedule or similar attachment to the U.S. Securities and Exchange Commission or its staff upon request.

**    Management contract or compensation plan or arrangement.

68

SIGNATURES

Pursuant to the requirements of the Securities Exchange Act of 1934, the registrant has duly caused this report to be signed on its behalf by the undersigned thereunto duly authorized.

Date: August 4, 2022	OPKO Health, Inc.
	/s/ Adam Logal
	Adam Logal
	Senior Vice President and Chief Financial
	Officer

69

EX-31.1

Exhibit 31.1

CERTIFICATIONS

I, Phillip Frost, certify that:

(1)I have reviewed this Quarterly Report on Form 10-Q of OPKO Health, Inc.;

(2)Based on my knowledge, this report does not contain any untrue statement of a material fact or omit to state a material fact necessary to make the statements made, in light of the circumstances under which such statements were made, not misleading with respect to the period covered by this report;

(3)Based on my knowledge, the financial statements, and other financial information included in this report, fairly present in all material respects the financial condition, results of operations and cash flows of the registrant as of, and for, the periods presented in this report;

(4)The registrant’s other certifying officer(s) and I are responsible for establishing and maintaining disclosure controls and procedures (as defined in Exchange Act Rules 13a-15(e) and 15d-15(e)) and internal control over financial reporting (as defined in Exchange Act Rules 13a-15(f) and 15d-15(f)) for the registrant and have:

a.Designed such disclosure controls and procedures, or caused such disclosure controls and procedures to be designed under our supervision, to ensure that material information relating to the registrant, including its consolidated subsidiaries, is made known to us by others within those entities, particularly during the period in which this report is being prepared;

b.Designed such internal control over financial reporting, or caused such internal control over financial reporting to be designed under our supervision, to provide reasonable assurance regarding the reliability of financial reporting and the preparation of financial statements for external purposes in accordance with generally accepted accounting principles;

c.Evaluated the effectiveness of the registrant’s disclosure controls and procedures and presented in this report our conclusions about the effectiveness of the disclosure controls and procedures, as of the end of the period covered by this report based on such evaluation; and

d.Disclosed in this report any change in the registrant’s internal control over financial reporting that occurred during the registrant’s most recent fiscal quarter (the registrant’s fourth fiscal quarter in the case of an annual report) that has materially affected, or is reasonably likely to materially affect, the registrant’s internal control over financial reporting; and

(5)The registrant’s other certifying officer(s) and I have disclosed, based on our most recent evaluation of internal control over financial reporting, to the registrant’s auditors and the audit committee of the registrant’s board of directors (or persons performing the equivalent functions):

a.All significant deficiencies and material weaknesses in the design or operation of internal control over financial reporting which are reasonably likely to adversely affect the registrant’s ability to record, process, summarize and report financial information; and

b.Any fraud, whether or not material, that involves management or other employees who have a significant role in the registrant’s internal control over financial reporting.

Date: August 4, 2022	/s/ Phillip Frost, M.D.
	Phillip Frost, M.D.
	Chief Executive Officer

EX-31.2

Exhibit 31.2

CERTIFICATIONS

I, Adam Logal, certify that:

(1)I have reviewed this Quarterly Report on Form 10-Q of OPKO Health, Inc.;

(2)Based on my knowledge, this report does not contain any untrue statement of a material fact or omit to state a material fact necessary to make the statements made, in light of the circumstances under which such statements were made, not misleading with respect to the period covered by this report;

(3)Based on my knowledge, the financial statements, and other financial information included in this report, fairly present in all material respects the financial condition, results of operations and cash flows of the registrant as of, and for, the periods presented in this report;

(4)The registrant’s other certifying officer(s) and I are responsible for establishing and maintaining disclosure controls and procedures (as defined in Exchange Act Rules 13a-15(e) and 15d-15(e)) and internal control over financial reporting (as defined in Exchange Act Rules 13a-15(f) and 15d-15(f)) for the registrant and have:

a.Designed such disclosure controls and procedures, or caused such disclosure controls and procedures to be designed under our supervision, to ensure that material information relating to the registrant, including its consolidated subsidiaries, is made known to us by others within those entities, particularly during the period in which this report is being prepared;

b.Designed such internal control over financial reporting, or caused such internal control over financial reporting to be designed under our supervision, to provide reasonable assurance regarding the reliability of financial reporting and the preparation of financial statements for external purposes in accordance with generally accepted accounting principles;

c.Evaluated the effectiveness of the registrant’s disclosure controls and procedures and presented in this report our conclusions about the effectiveness of the disclosure controls and procedures, as of the end of the period covered by this report based on such evaluation; and

d.Disclosed in this report any change in the registrant’s internal control over financial reporting that occurred during the registrant’s most recent fiscal quarter (the registrant’s fourth fiscal quarter in the case of an annual report) that has materially affected, or is reasonably likely to materially affect, the registrant’s internal control over financial reporting; and

(5)The registrant’s other certifying officer(s) and I have disclosed, based on our most recent evaluation of internal control over financial reporting, to the registrant’s auditors and the audit committee of the registrant’s board of directors (or persons performing the equivalent functions):

a.All significant deficiencies and material weaknesses in the design or operation of internal control over financial reporting which are reasonably likely to adversely affect the registrant’s ability to record, process, summarize and report financial information; and

b.Any fraud, whether or not material, that involves management or other employees who have a significant role in the registrant’s internal control over financial reporting.

Date: August 4, 2022	/s/ Adam Logal
	Adam Logal
	Senior Vice President and Chief Financial Officer

EX-32.1

Exhibit 32.1

Certification Pursuant to Section 906 of the Sarbanes-Oxley Act of 2002

(Subsections (a) and (b) of Section 1350, Chapter 63 of Title 18, United States Code)

Pursuant to 18 U.S.C. Section 1350, as adopted pursuant Section 906 of the Sarbanes-Oxley Act of 2002, I, Phillip Frost, Chief Executive Officer of OPKO Health, Inc. (the “Company”), hereby certify that:

The Quarterly Report on Form 10-Q for the quarterly period ended June 30, 2022 (the “Form 10-Q”) of the Company fully complies with the requirements of Section 13(a) or 15(d) of the Securities Exchange Act of 1934, and the information contained in the Form 10-Q fairly presents, in all material respects, the financial condition and results of operations of the Company.

Date: August 4, 2022	/s/ Phillip Frost, M.D.
	Phillip Frost, M.D.
	Chief Executive Officer

EX-32.2

Exhibit 32.2

Certification Pursuant to Section 906 of the Sarbanes-Oxley Act of 2002

(Subsections (a) and (b) of Section 1350, Chapter 63 of Title 18, United States Code)

Pursuant to 18 U.S.C. Section 1350, as adopted pursuant Section 906 of the Sarbanes-Oxley Act of 2002, I, Adam Logal, Chief Financial Officer of OPKO Health, Inc. (the “Company”), hereby certify that:

The Quarterly Report on Form 10-Q for the quarterly period ended June 30, 2022 (the “Form 10-Q”) of the Company fully complies with the requirements of Section 13(a) or 15(d) of the Securities Exchange Act of 1934, and the information contained in the Form 10-Q fairly presents, in all material respects, the financial condition and results of operations of the Company.

Date: August 4, 2022	/s/ Adam Logal
	Adam Logal
	Senior Vice President and Chief Financial Officer

XML

COVER PAGE - shares	6 Months Ended
	Jun. 30, 2022	Jul. 28, 2022
Cover [Abstract]
Document Type	10-Q
Document Quarterly Report	true
Document Period End Date	Jun. 30, 2022
Document Transition Report	false
Entity File Number	001-33528
Entity Registrant Name	OPKO Health, Inc.
Entity Incorporation, State or Country Code	DE
Entity Tax Identification Number	75-2402409
Entity Address, Address Line One	4400 Biscayne Blvd.
Entity Address, City or Town	Miami
Entity Address, State or Province	FL
Entity Address, Postal Zip Code	33137
City Area Code	(305)
Local Phone Number	575-4100
Title of 12(b) Security	Common Stock, par value $0.01 per share
Trading Symbol	OPK
Security Exchange Name	NASDAQ
Entity Current Reporting Status	Yes
Entity Interactive Data Current	Yes
Entity Filer Category	Large Accelerated Filer
Entity Small Business	false
Emerging Growth Company	false
Entity Shell Company	false
Entity Common Stock, Shares Outstanding (in shares)		771,959,579
Entity Central Index Key	0000944809
Amendment Flag	false
Document Fiscal Year Focus	2022
Document Fiscal Period Focus	Q2
Current Fiscal Year End Date	--12-31

XML

CONDENSED CONSOLIDATED BALANCE SHEETS - USD ($) $ in Thousands	Jun. 30, 2022	Dec. 31, 2021
Current assets:
Cash and cash equivalents	$ 210,458	$ 134,710
Accounts receivable, net	158,425	259,637
Inventory, net	83,306	86,502
Other current assets and prepaid expenses	42,563	27,170
Assets held for sale	0	314,994
Total current assets	494,752	823,013
Property, plant and equipment, net	78,601	79,727
Intangible assets, net	862,409	321,683
In-process research and development	195,000	590,200
Goodwill	578,845	520,601
Investments	108,685	10,729
Operating lease right-of-use assets	42,412	44,228
Other assets	8,898	9,534
Total assets	2,369,602	2,399,715
Current liabilities:
Accounts payable	56,107	82,040
Accrued expenses	128,254	193,493
Current maturities of operating leases	12,122	11,624
Liabilities associated with assets held-for-sale	0	28,156
Current portion of lines of credit and notes payable	18,989	14,695
Total current liabilities	215,472	330,008
Operating lease liabilities	30,876	33,097
Convertible notes	211,477	187,935
Deferred tax liabilities	176,741	148,487
Other long-term liabilities, principally contract liabilities, contingent consideration and lines of credit	16,237	15,062
Total long-term liabilities	435,331	384,581
Total liabilities	650,803	714,589
Equity:
Common Stock - $0.01 par value, 1,000,000,000 shares authorized; 780,591,681 and 690,082,283 shares issued at June 30, 2022 and December 31, 2021, respectively	7,806	6,901
#REF!	(1,791)	(1,791)
Additional paid-in capital	3,413,556	3,222,487
Accumulated other comprehensive loss	(49,171)	(30,495)
Accumulated deficit	(1,651,601)	(1,511,976)
Total shareholders’ equity	1,718,799	1,685,126
Total liabilities and equity	$ 2,369,602	$ 2,399,715

XML

CONDENSED CONSOLIDATED BALANCE SHEETS (Parenthetical) - $ / shares	Jun. 30, 2022	Dec. 31, 2021
Equity:
Common stock, par value (in dollars per share)	$ 0.01	$ 0.01
Common stock, shares authorized (in shares)	1,000,000,000	1,000,000,000
Common stock, shares issued (in shares)	780,591,681	690,082,283
Treasury stock, shares (in shares)	8,655,082

XML

CONDENSED CONSOLIDATED STATEMENTS OF OPERATIONS - USD ($) $ in Thousands	3 Months Ended		6 Months Ended
	Jun. 30, 2022	Jun. 30, 2021	Jun. 30, 2022	Jun. 30, 2021
Revenues:
Total revenues	$ 309,893	$ 442,408	$ 639,111	$ 987,573
Costs and expenses:
Selling, general and administrative	101,464	113,236	219,000	225,522
Research and development	17,254	18,222	35,566	37,537
Contingent consideration	175	(103)	69	(1,059)
Amortization of intangible assets	22,793	12,574	44,818	25,151
Gain on sale of assets	(15,365)	0	(15,365)	0
Total costs and expenses	320,632	436,837	722,275	943,565
Operating income (loss)	(10,739)	5,571	(83,164)	44,008
Other income and (expense), net:
Interest income	161	6	171	12
Interest expense	(3,075)	(4,887)	(5,737)	(10,282)
Fair value changes of derivative instruments, net	338	(272)	206	(711)
Other expense, net	(72,997)	(11,783)	(74,439)	(12,711)
Other expense, net	(75,572)	(16,936)	(79,799)	(23,692)
Income (loss) before income taxes and investment losses	(86,312)	(11,365)	(162,963)	20,316
Income tax benefit (provision)	(15,070)	(4,754)	6,196	(5,314)
Net income (loss) before investment losses	(101,382)	(16,119)	(156,766)	15,002
Loss from investments in investees	(268)	(67)	(316)	(110)
Net income (loss)	$ (101,650)	$ (16,186)	$ (157,083)	$ 14,892
Income (loss) per share, basic and diluted:
Income (loss) per share, basic (in dollars per share)	$ (0.14)	$ (0.03)	$ (0.23)	$ 0.02
Income (loss) per share, diluted (in dollars per share)	$ (0.14)	$ (0.03)	$ (0.23)	$ 0.02
Weighted average common shares outstanding, basic (in shares)	712,548,661	646,996,891	686,597,899	644,001,280
Weighted average common shares outstanding, diluted (in shares)	712,548,661	646,996,891	686,597,899	644,001,280
Services
Revenues:
Total revenues	$ 186,804	$ 397,197	$ 473,402	$ 904,149
Costs and expenses:
Cost of service revenue	171,836	267,807	393,039	607,235
Products
Revenues:
Total revenues	35,892	35,663	72,550	69,608
Costs and expenses:
Cost of service revenue	22,475	25,101	45,147	49,179
Revenue from transfer of intellectual property and other
Revenues:
Total revenues	$ 87,197	$ 9,548	$ 93,159	$ 13,816

XML

CONDENSED CONSOLIDATED STATEMENTS OF COMPREHENSIVE INCOME (LOSS) - USD ($) $ in Thousands	3 Months Ended		6 Months Ended
	Jun. 30, 2022	Jun. 30, 2021	Jun. 30, 2022	Jun. 30, 2021
Statement of Comprehensive Income [Abstract]
Net income (loss)	$ (101,650)	$ (16,186)	$ (157,083)	$ 14,892
Other comprehensive loss, net of tax:
Change in foreign currency translation and other comprehensive loss	(17,756)	(9,070)	(18,676)	(9,070)
Comprehensive income (loss)	$ (119,406)	$ (25,256)	$ (175,759)	$ 5,822

XML

CONSOLIDATED STATEMENTS OF EQUITY - USD ($) $ in Thousands	Total	Cumulative Effect, Period of Adoption, Adjustment	Common Stock	Treasury	Additional Paid-In Capital	Additional Paid-In Capital Cumulative Effect, Period of Adoption, Adjustment	Accumulated Other Comprehensive Income (loss)	Accumulated Deficit	Accumulated Deficit Cumulative Effect, Period of Adoption, Adjustment
Beginning balance, shares (in shares) at Dec. 31, 2020			670,585,576
Beginning balance, shares (in shares) at Dec. 31, 2020				(549,907)
Beginning balance at Dec. 31, 2020	$ 1,671,551		$ 6,706	$ (1,791)	$ 3,152,694		$ (4,225)	$ (1,481,833)
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Equity-based compensation expense	6,107				6,107
Exercise of common stock options and warrants (in shares)			181,125
Exercise of common stock options and warrants	467		$ 2		465
2025 convertible notes (in shares)			19,051,270	(8,105,175)
2025 convertible notes	55,275		$ 190		55,085
Net income (loss)	14,892							14,892
Other comprehensive income (loss)	(5,707)						(5,707)
Ending balance, shares (in shares) at Jun. 30, 2021			689,817,971
Ending balance, shares (in shares) at Jun. 30, 2021				(8,655,082)
Ending balance at Jun. 30, 2021	1,742,585		$ 6,898	$ (1,791)	3,214,351		(9,932)	(1,466,941)
Beginning balance, shares (in shares) at Dec. 31, 2020			670,585,576
Beginning balance, shares (in shares) at Dec. 31, 2020				(549,907)
Beginning balance at Dec. 31, 2020	1,671,551		$ 6,706	$ (1,791)	3,152,694		(4,225)	(1,481,833)
Ending balance, shares (in shares) at Dec. 31, 2021			690,082,283
Ending balance, shares (in shares) at Dec. 31, 2021				(8,655,082)
Ending balance at Dec. 31, 2021	$ 1,685,126	$ (21,642)	$ 6,901	$ (1,791)	3,222,487	$ (39,100)	(30,495)	(1,511,976)	$ 17,458
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Accounting Standards Update [Extensible List]	Accounting Standards Update 2020-06
Beginning balance, shares (in shares) at Mar. 31, 2021			670,703,076
Beginning balance, shares (in shares) at Mar. 31, 2021				(549,907)
Beginning balance at Mar. 31, 2021	$ 1,696,514		$ 6,707	$ (1,791)	3,155,648		(13,295)	(1,450,755)
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Equity-based compensation expense	3,460				3,460
Exercise of common stock options and warrants (in shares)			63,625
Exercise of common stock options and warrants	159		$ 1		158
2025 convertible notes (in shares)			19,051,270	(8,105,175)
2025 convertible notes	55,275		$ 190		55,085
Net income (loss)	(16,186)							(16,186)
Other comprehensive income (loss)	3,363						3,363
Ending balance, shares (in shares) at Jun. 30, 2021			689,817,971
Ending balance, shares (in shares) at Jun. 30, 2021				(8,655,082)
Ending balance at Jun. 30, 2021	1,742,585		$ 6,898	$ (1,791)	3,214,351		(9,932)	(1,466,941)
Beginning balance, shares (in shares) at Dec. 31, 2021			690,082,283
Beginning balance, shares (in shares) at Dec. 31, 2021				(8,655,082)
Beginning balance at Dec. 31, 2021	1,685,126	$ (21,642)	$ 6,901	$ (1,791)	3,222,487	$ (39,100)	(30,495)	(1,511,976)	$ 17,458
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Equity-based compensation expense	11,925				11,925
Exercise of common stock options and warrants (in shares)			602,087
Exercise of common stock options and warrants	(225)		$ 6		(231)
ModeX Acquisition (in shares)			89,907,311
ModeX Acquisition	219,374		$ 899		218,475
Net income (loss)	(157,083)							(157,083)
Other comprehensive income (loss)	$ (18,676)						(18,676)
Ending balance, shares (in shares) at Jun. 30, 2022			780,591,681
Ending balance, shares (in shares) at Jun. 30, 2022	(8,655,082)			(8,655,082)
Ending balance at Jun. 30, 2022	$ 1,718,799		$ 7,806	$ (1,791)	3,413,556		(49,171)	(1,651,601)
Beginning balance, shares (in shares) at Mar. 31, 2022			690,138,033
Beginning balance, shares (in shares) at Mar. 31, 2022				(8,655,082)
Beginning balance at Mar. 31, 2022	1,614,884		$ 6,901	$ (1,791)	3,191,139		(31,415)	(1,549,951)
Increase (Decrease) in Stockholders' Equity [Roll Forward]
Equity-based compensation expense	4,308				4,308
Exercise of common stock options and warrants (in shares)			546,337
Exercise of common stock options and warrants	(360)		$ 6		(366)
Net income (loss)	(101,650)							(101,650)
Other comprehensive income (loss)	$ (17,756)						(17,756)
Ending balance, shares (in shares) at Jun. 30, 2022			780,591,681
Ending balance, shares (in shares) at Jun. 30, 2022	(8,655,082)			(8,655,082)
Ending balance at Jun. 30, 2022	$ 1,718,799		$ 7,806	$ (1,791)	$ 3,413,556		$ (49,171)	$ (1,651,601)

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CONDENSED CONSOLIDATED STATEMENTS OF CASH FLOWS - USD ($) $ in Thousands	6 Months Ended
	Jun. 30, 2022	Jun. 30, 2021
Cash flows from operating activities:
Net income (loss)	$ (157,083)	$ 14,892
Adjustments to reconcile net income (loss) to net cash (used in) provided by operating activities:
Depreciation and amortization	55,809	40,561
Non-cash interest	1,364	4,981
Amortization of deferred financing costs	569	424
Losses from investments in investees	316	110
Equity-based compensation – employees and non-employees	11,925	6,107
Realized loss (gain) on disposal of fixed assets and sales of equity securities	(477)	(3,146)
Loss on conversion of the 2025 Notes	0	11,111
Change in fair value of equity securities and derivative instruments	73,724	873
Change in fair value of contingent consideration	69	(1,059)
Gain on sale of GeneDx	(15,365)	0
Deferred income tax benefit	(8,942)	2,479
Changes in assets and liabilities:
Accounts receivable, net	95,864	20,352
Inventory, net	2,864	(3,817)
Other current assets and prepaid expenses	(6,502)	(13,904)
Other assets	(260)	1,388
Accounts payable	(19,508)	(11,651)
Foreign currency measurement	4,295	(2,532)
Contract liabilities	(17)	(7,425)
Accrued expenses and other liabilities	(69,978)	(49,159)
Net cash (used in) provided by operating activities	(31,333)	10,585
Cash flows from investing activities:
Proceeds from sale of investments	0	8,079
Proceeds from sale of GeneDx	115,423	0
Acquisition of businesses, net of cash	(2,071)	0
Proceeds from the sale of property, plant and equipment	870	165
Capital expenditures	(10,630)	(18,192)
Net cash provided by (used in) investing activities	103,592	(9,948)
Cash flows from financing activities:
Issuance of common stock	1	0
Proceeds from the exercise of common stock options	(225)	465
Borrowings on lines of credit	684,467	982,797
Repayments of lines of credit	(679,860)	(990,190)
Net cash provided by (used in) financing activities	4,383	(6,928)
Effect of exchange rate changes on cash and cash equivalents	(894)	(163)
Net increase (decrease) in cash and cash equivalents	75,748	(6,454)
Cash and cash equivalents at beginning of period	134,710	72,211
Cash and cash equivalents at end of period	210,458	65,757
SUPPLEMENTAL INFORMATION:
Interest paid	3,554	4,883
Income taxes paid, net of refunds	4,647	3,690
Non-cash financing:
Shares issued upon the conversion of-2025 Convertible Notes	0	68,775
Shares issued upon the conversion of: Common stock options and warrants, surrendered in net exercise	655	0
Shares issued upon the conversion of- Issuance of common stock for acquisition of ModeX	219,374	0
Fair value of shares included in consideration from Sema4	$ 172,000	$ 0

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Business and Organization

6 Months Ended

Jun. 30, 2022

Organization, Consolidation and Presentation of Financial Statements [Abstract]

BUSINESS AND ORGANIZATION

BUSINESS AND ORGANIZATION

We are a diversified healthcare company that seeks to establish industry-leading positions in large and rapidly growing medical markets. Our diagnostics business includes BioReference Health, LLC, formerly known as BioReference Laboratories, Inc. (“BioReference”), one of the nation’s largest full service laboratories with an almost 250-person sales and marketing team to drive growth and leverage new products. Our pharmaceutical business features Rayaldee, a U.S. Food and Drug Administration (“FDA”) approved treatment for secondary hyperparathyroidism (“SHPT”) in adults with stage 3 or 4 chronic kidney disease (“CKD”) and vitamin D insufficiency and a pipeline of products in various stages of development. Our leading product in development is Somatrogon (hGH-CTP), a once-weekly human growth hormone for which we have partnered with Pfizer, Inc. (“Pfizer”) and successfully completed a phase 3 study in August 2019. Regulatory applications for Somatrogon (hGH-CTP) have been submitted to the applicable regulatory bodies for review in several countries around the world. In February 2022, the European Commission granted marketing authorization in the European Union for Somatrogon (hGH-CTP) under the brand name NGENLA® to treat children and adolescents from as young as three years of age with growth disturbance due to insufficient secretion of growth hormone, and we recently received pricing approval in Germany. In January 2022, the Ministry of Health, Labour and Welfare in Japan approved NGENLA® (Somatrogon) for the long-term treatment of pediatric patients who have growth failure due to an inadequate secretion of endogenous growth hormone and we recently received pricing approval. In October 2021, Health Canada approved NGENLA® for the long-term treatment of pediatric patients who have growth hormone deficiency, and Australia’s Therapeutic Goods Administration approved NGENLA® for the long-term treatment of pediatric patients with growth disturbance due to insufficient secretion of growth hormone. Pfizer submitted the initial Biologics License Application (“BLA”) with the FDA for approval of Somatrogon (hGH-CTP) in the United States and received a Complete Response Letter in January 2022. Pfizer and OPKO are evaluating the FDA’s comments and will work with the agency to determine the best path forward for Somatrogon (hGH-CTP) in the United States. We are incorporated in Delaware, and our principal executive offices are located in leased offices in Miami, Florida.

Through BioReference, we provide laboratory testing services, primarily to customers in the larger metropolitan areas in New York, New Jersey, Florida, Texas, Maryland, California, Pennsylvania, Delaware, Washington, DC, Illinois and Massachusetts, as well as to customers in a number of other states. We offer a comprehensive test menu of clinical diagnostics for blood, urine and tissue analysis. This includes hematology, clinical chemistry, immunoassay, infectious diseases, serology, hormones, and toxicology assays, as well as Pap smear, anatomic pathology (biopsies) and other types of tissue analysis. We market our laboratory testing services directly to physicians, geneticists, hospitals, clinics, correctional and other health facilities.

We operate established pharmaceutical platforms in Ireland, Chile, Spain, and Mexico, which are generating revenue and from which we expect to generate positive cash flow and facilitate future market entry for our products currently in development. In addition, we have a development and commercial supply pharmaceutical company and a global supply chain operation and holding company in Ireland. We own a specialty active pharmaceutical ingredients (“APIs”) manufacturer in Israel, which we expect will facilitate the development of our pipeline of molecules and compounds for our proprietary molecular diagnostic and therapeutic products.

Our research and development activities are primarily performed at facilities in Woburn, MA, Waterford, Ireland, Kiryat Gat, Israel, and Barcelona, Spain.

On May 9, 2022 (the “Closing Date”), the Company entered into an Agreement and Plan of Merger (the “ModeX Merger Agreement”) with Orca Acquisition Sub, Inc., a Delaware corporation and wholly owned subsidiary of the Company (“Merger Sub”), ModeX Therapeutics, Inc., a Delaware corporation (“ModeX”) and Gary J. Nabel, solely in his capacity as sellers’ representative, pursuant to which Merger Sub merged with and into ModeX (the “ModeX Merger”), with ModeX surviving the ModeX Merger as a wholly owned subsidiary of the Company. The Company paid the entirety of the $300.0 million purchase price pursuant to the issuance of an aggregate of 89,907,310 shares (the “Consideration Shares”) of the Company’s common stock, par value $0.01 per share (“Common Stock”), to the former stockholders of ModeX (the “Selling Stockholders”), of which 10% of such shares were deposited in a twelve-month escrow for purposes of satisfying the potential indemnity obligations of the Selling Stockholders under the ModeX Merger Agreement. Additionally, the Company issued equity awards to ModeX employees in an amount equal to $12.4 million, which was deducted from the consideration payable on the Closing Date. If any of such awards are forfeited or otherwise remain unvested on the four-year anniversary of the Closing Date, up to $2.6 million shares of Common Stock (valued at the same price used for determining the number of Consideration Shares issuable upon consummation of the ModeX Merger) may be distributed pro rata to ModeX’s former stockholders in respect of such forfeited or unvested awards. Shares of Common Stock with respect to such potential distribution have been escrowed and will remain escrowed for such four-year period. For accounting purposes, the shares were valued at $219.4 million, based on

the closing price per share of our Common Stock of $2.44 as reported by NASDAQ Global Select Market (“NASDAQ”) on the Closing Date.

In connection with the ModeX Merger, the Company appointed Elias A. Zerhouni, M.D., Gary J. Nabel, M.D., PhD., and Alexis Borisy to the Board of Directors of the Company (the “Board”), with Dr. Zerhouni serving as Vice Chair. Elizabeth Nabel, one of the founders of ModeX, was appointed as the Company’s new Chief Medical Officer. Dr. Gary J. Nabel has been named the Chief Executive Officer of ModeX and Chief Innovation Officer of the Company and Dr. Elias A.Zerhouni has been named the President of the Company.

In accordance with the ModeX Merger Agreement, Dr. Phillip Frost, the Company’s Chief Executive Officer and Chairman of the Board, Dr. Jane Hsiao, the Company’s Chief Technical Officer and a Director, and Frost Gamma Investments Trust (“FGIT”), a trust controlled by Dr. Frost, entered into a lockup and voting agreement, together with the Company (the “ModeX Lockup and Voting Agreement”), pursuant to which: (i) FGIT has agreed that, for a period of four years immediately following the Closing Date, it will not sell or otherwise transfer its shares of Common Stock, subject to certain customary exceptions; and (ii) Drs. Frost and Hsiao agreed that, for as long as Dr. Elias A. Zerhouni or Dr. Gary J. Nabel remains an employee of the Company or ModeX, Drs. Frost and Hsiao will vote, or cause to be voted, all of their respective shares of Common Stock in favor of such person’s election to the Board. Additionally, in accordance with the ModeX Merger Agreement, certain recipients of the Consideration Shares, holding in aggregate approximately 88.0% of the Consideration Shares, agreed not to sell or otherwise transfer their respective Consideration Shares for a period of four years immediately following the Closing Date on the same terms as contained in the ModeX Lockup and Voting Agreement.

On January 14, 2022, the Company entered into an Agreement and Plan of Merger and Reorganization (the “GeneDx Merger Agreement”) with Sema4 Holdings Corp., a Delaware corporation (“Sema4”), pursuant to which Sema4 acquired the Company’s former subsidiary, GeneDx LLC, (f/k/a GeneDx, Inc. “GeneDx”), (the “GeneDx Transaction”) in a transaction that closed on April 29, 2022 (the “GeneDx Closing”).

Upon the GeneDx Closing, Sema4 paid to the Company aggregate consideration of $150 million in cash (before deduction of transaction expenses and other customary purchase price adjustments), together with 80.0 million shares (the “Closing Shares”) of Sema4’s Class A common stock, par value $0.0001 per share (“Sema4 Common Stock”). Additionally, Sema4 has agreed to pay the Company up to an additional $150 million, which may be paid in Sema4 Common Stock, cash or a combination thereof in Sema4’s discretion, subject to GeneDx achieving certain revenue targets for the fiscal years ending December 31, 2022 and 2023 (the “Milestone Consideration”). Based on the closing price of Sema4 Common Stock on April 29, 2022, the total upfront consideration was approximately $322 million, and the total aggregate consideration, including the potential Milestone Consideration, was approximately $447 million. We recognized a gain of $15.4 million on the sale of GeneDx during the second quarter of 2022.

In connection with the transactions contemplated by the GeneDx Merger Agreement, on January 14, 2022, the Company entered into a Shareholder Agreement (the “Sema4 Shareholder Agreement”) with Sema4, pursuant to which the Company has agreed to, among other things, be subject to a lock-up period with respect to its shares of Sema4 Common Stock, which expires on April 29, 2024 with respect to the Closing Shares, and, if earned and received, would extend for periods of one-year and six-months following the issuance of shares, cash or a combination thereof, in respect of the first and second potential Milestone Consideration payments, respectively.

Pursuant to the GeneDx Merger Agreement, the Company designated, and Sema4 nominated for election an individual to serve on the board of directors of Sema4, and such nominee was elected by Sema4’s stockholders to serve as a director until Sema4’s 2024 annual meeting of stockholders. In addition, the Company has further agreed to certain standstill provisions whereby, subject to certain exceptions, it is obligated to refrain from taking certain actions with respect to the Sema4 Common Stock. The Company has also agreed to vote its shares of Sema4 Common Stock in accordance with the recommendations of Sema4’s board of directors for so long as it continues to hold at least 5% of the outstanding shares of Sema4 Common Stock. Further, Sema4 has also granted the Company certain customary shelf, piggyback and demand registration rights that require Sema4 to register the Company’s Sema4 Lock-Up Shares for resale under the Securities Act. OPKO’s intention is that we will no longer have a designee serving on Sema4’s board of directors upon the expiration of the Sema4 Lock-Up Period. As such, OPKO is not actively participating in the policy-making process of Sema4.

As of December 31, 2021, GeneDx met the held-for-sale accounting criteria and, its related assets and liabilities are classified as held for sale in the consolidated balance sheet. GeneDx was included in our diagnostics segment as of December 31, 2021.

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Impact of COVID-19

6 Months Ended

Jun. 30, 2022

Unusual or Infrequent Items, or Both [Abstract]

IMPACT OF COVID-19

IMPACT OF COVID-19

We continue to be a part of the coordinated public and private sector response to SARS-CoV-2, a novel strain of coronavirus, referred to as COVID-19. There continues to be a high level of uncertainty relating to how the pandemic will evolve, how governments and consumers will react, progress on the distribution of vaccines and whether the pandemic will have a longer-term effect on the healthcare industry and patient habits. BioReference is providing COVID-19 solutions, including diagnostic molecular testing and serology antibody testing, to meet the testing needs of its customers, including physicians, health systems, long-term care facilities, governments, schools, employers, professional sports teams and entertainment venues, as well as the general public through relationships with retail pharmacy chains.

Since the pandemic began in the U.S., we have invested in testing capabilities and infrastructure to meet demand for our molecular and antibody testing for COVID-19. Throughout the pandemic, we have managed our company-wide lab operations specimen acquisition, logistics, procurement, customer service, and initiatives to manage our cost structure to match the ever changing COVID-19 testing volumes and to manage efficiency gains in our core clinical lines of business. We anticipate that COVID-19 will continue to impact our business in 2022 and, overall, we expect COVID-19 test demand to continue to decline in 2022 as compared to 2021.

Revenue from services for the six months ended June 30, 2022 decreased by $430.7 million as compared to 2021 due to lower COVID-19 testing volumes. Excluding COVID-19 test volumes, for the six months ended June 30, 2022, routine clinical test volume decreased 26.2% as compared to volumes for the six months ended June 30, 2021.

In March 2022, the U.S. Health Resources and Services Administration ("HRSA") informed providers that, after March 22, 2022, it would stop accepting claims for testing and treatment for uninsured individuals under the HRSA COVID-19 Uninsured Program and that claims submitted prior to that date would be subject to eligibility and availability of funds. For the six months ended June 30, 2022, revenue for testing of uninsured individuals under the HRSA COVID-19 Uninsured Program represented approximately 5.7% of our COVID-19 testing revenue. As of June 30, 2022, less than 2% of our net accounts receivable was associated with claims for reimbursement for COVID-19 testing of uninsured individuals. Although we believe that our estimates for contractual allowances and patient price concessions are appropriate, actual results could differ from those estimates.

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Summary of Significant Accounting Policies

6 Months Ended

Jun. 30, 2022

Accounting Policies [Abstract]

SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES

SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES

Basis of presentation. The accompanying unaudited Condensed Consolidated Financial Statements have been prepared in accordance with accounting principles generally accepted in the U.S. (“GAAP”) and with the instructions to Form 10-Q and Article 10 of Regulation S-X. Accordingly, they do not include all information and notes required by GAAP for complete financial statements. In the opinion of management, all adjustments (consisting of only normal recurring adjustments or adjustments otherwise disclosed herein) considered necessary to present fairly the Company’s results of operations, financial position and cash flows have been made. The results of operations and cash flows for the six months ended June 30, 2022 are not necessarily indicative of the results of operations and cash flows that may be reported for the remainder of 2022 or any other future periods. The unaudited Condensed Consolidated Financial Statements should be read in conjunction with the audited Consolidated Financial Statements and the Notes to Consolidated Financial Statements included in our Annual Report on Form 10-K for the year ended December 31, 2021.

Principles of consolidation. The accompanying unaudited Condensed Consolidated Financial Statements include the accounts of OPKO Health, Inc. and our wholly-owned subsidiaries. All intercompany accounts and transactions are eliminated in consolidation.

Use of estimates. The preparation of financial statements in conformity with GAAP requires management to make estimates and assumptions that affect the reported amounts of assets and liabilities and disclosure of contingent assets and liabilities at the date of the financial statements and the reported amounts of revenues and expenses during the reporting period. Actual results could differ significantly from these estimates.

Cash and cash equivalents. Cash and cash equivalents include short-term, interest-bearing instruments with original maturities of 90 days or less at the date of purchase. We also consider all highly liquid investments with original maturities at the date of purchase of 90 days or less as cash equivalents. These investments include money markets, bank deposits, certificates of deposit and U.S. treasury securities.

Inventories. Inventories are valued at the lower of cost and net realizable value. Cost is determined by the first-in, first-out method. We consider such factors as the amount of inventory on hand, estimated time required to sell such inventories, remaining shelf-life, and current market conditions to determine whether inventories are stated at the lower of cost and net realizable value. Inventories at our diagnostics segment consist primarily of purchased laboratory supplies, which are used in our testing laboratories. Inventory obsolescence expense for the three and six months ended June 30, 2022 was $0.3 million and $1.0 million, respectively. Inventory obsolescence expense for the three and six months ended June 30, 2021 was $0.9 million and $3.9 million, respectively.

Goodwill and intangible assets. Goodwill represents the difference between the purchase price and the estimated fair value of the net assets acquired accounted for by the acquisition method of accounting. Refer to Note 5. Goodwill, in-process research and development (“IPR&D”) and other intangible assets acquired in business combinations, licensing and other transactions was $1.6 billion and $1.4 billion, respectively, at June 30, 2022 and December 31, 2021.

Assets acquired and liabilities assumed in business combinations, licensing and other transactions are generally recognized at the date of acquisition at their respective fair values. Any excess of the purchase price over the estimated fair values of the net assets acquired is recognized as goodwill. At acquisition, we generally determine the fair value of intangible assets, including IPR&D, using the “income method.”

Subsequent to their acquisition, goodwill and indefinite lived intangible assets are tested at least annually as of October 1 for impairment, or when events or changes in circumstances indicate it is more likely than not that the carrying amount of such assets may not be recoverable.

Estimating the fair value of a reporting unit for goodwill impairment is highly sensitive to changes in projections and assumptions and changes in assumptions could potentially lead to impairment. We perform sensitivity analyses around our assumptions in order to assess the reasonableness of the assumptions and the results of our testing. Ultimately, potential changes in these assumptions may impact the estimated fair value of a reporting unit and result in an impairment if the fair value of such reporting unit is less than its carrying value. Goodwill was $578.8 million and $520.6 million, respectively, at June 30, 2022 and December 31, 2021. At December 31, 2021, Assets held for sale include $151.8 million of goodwill related to GeneDx.

Net intangible assets other than goodwill was $1,057.4 million and $911.9 million, including IPR&D of $195.0 million and $590.2 million at June 30, 2022 and December 31, 2021, respectively. Intangible assets are highly vulnerable to impairment charges, particularly newly acquired assets for recently launched products and IPR&D. Considering the high risk nature of research and development and the industry’s success rate of bringing developmental compounds to market, IPR&D impairment charges may occur in future periods. Estimating the fair value of IPR&D for potential impairment is highly sensitive to changes in projections and assumptions and changes in assumptions could potentially lead to impairment.

Upon obtaining regulatory approval, IPR&D assets are then accounted for as a finite-lived intangible asset and amortized on a straight-line basis over its estimated useful life. If the project is abandoned, the IPR&D asset is charged to expense. Finite lived intangible assets are tested for impairment when events or changes in circumstances indicate it is more likely than not that the carrying amount of such assets may not be recoverable. The testing includes a comparison of the carrying amount of the asset to its estimated undiscounted future cash flows expected to be generated by the asset. If the carrying amount of an asset exceeds its estimated undiscounted future cash flows, then an impairment charge is recognized for the amount by which the carrying amount of the asset exceeds the fair value of the asset.

We believe that our estimates and assumptions in testing goodwill and other intangible assets, including IPR&D, for

impairment are reasonable and otherwise consistent with assumptions that marketplace participants would use in their estimates

of fair value. However, if future results are not consistent with our estimates and assumptions, including as a result of the

COVID-19 global pandemic, then we may be exposed to additional impairment charges, which could be material. Pfizer submitted the initial BLA with the FDA for approval of Somatrogon (hGH-CTP) in the United States and Pfizer received a Complete Response Letter in January 2022. Pfizer and OPKO are evaluating the FDA’s comments and will work with the agency to determine the best path forward for Somatrogon (hGH-CTP) in the United States.

In the first quarter of 2022, we reclassified $590.0 million of IPR&D related to Somatrogon (hGH-CTP) from IPR&D in our Condensed Consolidated Balance Sheet upon the approval of NGENLA (Somatrogon) in Europe and Japan. The assets will be amortized on a straight-line basis over their estimated useful life of approximately 12 years.

We amortize intangible assets with definite lives on a straight-line basis over their estimated useful lives, ranging from 3 to 20 years. We use the straight-line method of amortization as there is no reliably determinable pattern in which the economic benefits of our intangible assets are consumed or otherwise used up. Amortization expense was $44.8 million and $25.2 million for the six months ended June 30, 2022 and 2021, respectively.

Fair value measurements. The carrying amounts of our cash and cash equivalents, accounts receivable, accounts payable and short-term debt approximate their fair value due to the short-term maturities of these instruments. Investments that are considered equity securities as of June 30, 2022 and December 31, 2021 are predominately carried at fair value. Our debt under the Credit Agreement (as defined below) approximates fair value due to the variable rate of interest applicable to such debt.

In evaluating the fair value information, considerable judgment is required to interpret the market data used to develop the estimates. The use of different market assumptions and/or different valuation techniques may have a material effect on the

estimated fair value amounts. Accordingly, the estimates of fair value presented herein may not be indicative of the amounts that could be realized in a current market exchange. Refer to Note 9.

Contingent consideration. Each period we revalue the contingent consideration obligations associated with certain prior acquisitions to their fair value and record increases in the fair value as contingent consideration expense and decreases in the fair value as a reduction in contingent consideration expense. Changes in contingent consideration result from changes in the assumptions regarding probabilities of successful achievement of related milestones, the estimated timing in which the milestones are achieved and the discount rate used to estimate the fair value of the liability. Contingent consideration may change significantly as our development programs progress, revenue estimates evolve and additional data is obtained, impacting our assumptions. The assumptions used in estimating fair value require significant judgment. The use of different assumptions and judgments could result in a materially different estimate of fair value which may have a material impact on our results from operations and financial position.

Derivative financial instruments. We record derivative financial instruments on our Condensed Consolidated Balance Sheet at their fair value and recognize the changes in the fair value in our Condensed Consolidated Statement of Operations when they occur, the only exception being derivatives that qualify as hedges. For the derivative instrument to qualify as a hedge, we are required to meet strict hedge effectiveness and contemporaneous documentation requirements at the initiation of the hedge and assess the hedge effectiveness on an ongoing basis over the life of the hedge. At June 30, 2022 and December 31, 2021, our foreign currency forward contracts held to economically hedge inventory purchases did not meet the documentation requirements to be designated as hedges. Accordingly, we recognized all changes in the fair values of our derivatives instruments, net, in our Condensed Consolidated Statement of Operations. Refer to Note 10.

Property, plant and equipment. Property, plant and equipment are recorded at cost or fair value if acquired in a business combination. Depreciation is provided using the straight-line method over the estimated useful lives of the assets and includes amortization expense for assets capitalized under finance leases. The estimated useful lives by asset class are as follows: software - 3 years, machinery, medical and other equipment - 5-8 years, furniture and fixtures - 5-12 years, leasehold improvements - the lesser of their useful life or the lease term, buildings and improvements - 10-40 years, and automobiles - 3-5 years. Expenditures for repairs and maintenance are charged to expense as incurred. Assets held under finance leases are included within Property, plant and equipment, net in our Consolidated Balance Sheets and are amortized over the shorter of their useful lives or the expected term of their related leases. Depreciation expense was $5.2 million and $11.0 million for the three and six months ended June 30, 2022, respectively. Depreciation expense was $8.0 million and $15.4 million for three and six months ended June 30, 2021, respectively.

Impairment of long-lived assets. Long-lived assets, such as property and equipment and assets held for sale, are reviewed for impairment whenever events or changes in circumstances indicate that the carrying amount of an asset may not be recoverable. Recoverability of assets to be held and used is measured by a comparison of the carrying amount of an asset to estimated undiscounted future cash flows expected to be generated by the asset. If the carrying amount of an asset exceeds its estimated future cash flows, then an impairment charge is recognized for the amount by which the carrying amount of the asset exceeds the fair value of the asset.

Income taxes. Income taxes are accounted for under the asset-and-liability method. Deferred tax assets and liabilities are recognized for the future tax consequences attributable to differences between the financial statement carrying amounts of existing assets and liabilities and the respective tax bases and for operating loss and tax credit carryforwards. Deferred tax assets and liabilities are measured using enacted tax rates expected to apply to taxable income in the years in which those temporary differences are expected to be recovered or settled. The effect on deferred tax assets and liabilities of a change in tax rates is recognized in operations in the period that includes the enactment date. We periodically evaluate the realizability of our net deferred tax assets. Our tax accruals are analyzed periodically and adjustments are made as events occur to warrant such adjustment. Valuation allowances on certain U.S. deferred tax assets and non-U.S. deferred tax assets are established, because realization of these tax benefits through future taxable income does not meet the more-likely-than-not threshold.

We operate in various countries and tax jurisdictions globally.  For interim reporting purposes, we record income taxes based on the expected effective income tax rate, taking into consideration year to date and global forecasted tax results.  For the six months ended June 30, 2022, the tax rate differed from the U.S. federal statutory rate of 21% primarily due to the valuation allowance against certain U.S. and non-U.S. deferred tax assets, the relative mix in earnings and losses in the U.S. versus foreign tax jurisdictions, and the impact of certain discrete tax events and operating results in tax jurisdictions which do not result in a tax benefit.

Revenue recognition. We recognize revenue when a customer obtains control of promised goods or services in accordance with Accounting Standards Codification Topic 606, Revenue from Contracts with Customers (“Topic 606”). The amount of revenue that is recorded reflects the consideration that we expect to receive in exchange for those goods or services.

We apply the following five-step model in order to determine this amount: (i) identify the contract(s) with a customer; (ii) identify the performance obligations in the contract; (iii) determine the transaction price; (iv) allocate the transaction price to the performance obligations in the contract; and (v) recognize revenue when (or as) we satisfy a performance obligation.

We apply the five-step model to contracts when it is probable that we will collect the consideration we are entitled to in exchange for the goods or services we transfer to the customer. At contract inception, once the contract is determined to be within the scope of Topic 606, we review the contract to determine which performance obligations we must deliver and which of these performance obligations are distinct. We recognize as revenue the amount of the transaction price that is allocated to the respective performance obligation when the performance obligation is satisfied or as it is satisfied. For a complete discussion of accounting for Revenues from services, Revenues from products and Revenue from transfer of intellectual property and other, refer to Note 13.

Concentration of credit risk and allowance for credit losses. Financial instruments that potentially subject us to concentrations of credit risk consist primarily of accounts receivable. Substantially all of our accounts receivable are with either companies in the healthcare industry or patients. However, credit risk is limited due to the number of our clients as well as their dispersion across many different geographic regions.

While we have receivables due from federal and state governmental agencies, we do not believe that such receivables represent a credit risk because the related healthcare programs are funded by federal and state governments, and payment is primarily dependent upon submitting appropriate documentation. On June 30, 2022 and December 31, 2021, receivable balances (net of explicit and implicit price concessions) from Medicare and Medicaid were 12% and 6%, respectively, of our consolidated Accounts receivable, net. On June 30, 2022 and December 31, 2021, receivable balances (net of explicit and implicit price concessions) due directly from states, cities and other municipalities, specifically related to our real-time reverse-transcription polymerase chain reaction (real-time RT-PCR) assay to detect COVID-19, were 3.9% and 4.1% of our consolidated accounts receivable, net, respectively.

The portion of our accounts receivable due from individual patients comprises the largest portion of credit risk. At June 30, 2022 and December 31, 2021, receivables due from patients represented approximately 2.3% and 0.7%, respectively, of our consolidated Accounts receivable, net.

We assess the collectability of accounts receivable balances by considering factors such as historical collection experience, customer credit worthiness, the age of accounts receivable balances, regulatory changes and current economic conditions and trends that may affect a customer’s ability to pay. Actual results could differ from those estimates. The allowance for credit losses was $6.8 million and $1.8 million at June 30, 2022 and December 31, 2021, respectively. The credit loss expense for the three and six months ended June 30, 2022 was $0.1 million and $0.2 million, respectively. The credit loss expense for the three and six months ended June 30, 2021 was $0.3 million and $0.6 million, respectively.

Equity-based compensation. We measure the cost of services received in exchange for an award of equity instruments based on the grant-date fair value of the award. That cost is recognized in the Condensed Consolidated Statement of Operations over the period during which an employee is required to provide service in exchange for the award. We record excess tax benefits realized from the exercise of stock options as cash flows from operations. For the three and six months ended June 30, 2022 we recorded $4.3 million and $11.9 million, respectively, of equity-based compensation expense. For the three and six months ended June 30, 2021 we recorded $3.5 million and $6.1 million, respectively, of equity-based compensation expense.

Research and development expenses. Research and development expenses include external and internal expenses. External expenses include clinical and non-clinical activities performed by contract research organizations, lab services, purchases of drug and diagnostic product materials and manufacturing development costs. Research and development employee-related expenses include salaries, benefits and equity-based compensation expense. Other internal research and development expenses are incurred to support overall research and development activities and include expenses related to general overhead and facilities. We expense these costs in the period in which they are incurred. We estimate our liabilities for research and development expenses in order to match the recognition of expenses to the period in which the actual services are received. As such, accrued liabilities related to third party research and development activities are recognized based upon our estimate of services received and degree of completion of the services in accordance with the specific third party contract.

Research and development expense includes costs for in-process research and development projects acquired in asset acquisitions which have not reached technological feasibility, and which have no alternative future use. For in-process research and development projects acquired in business combinations, the in-process research and development project is capitalized and evaluated for impairment until the development process has been completed. Once the development process has been completed the asset will be amortized over its remaining estimated useful life.

Segment reporting. Our chief operating decision-maker (“CODM”) is Phillip Frost, M.D., our Chairman and Chief Executive Officer. Our CODM reviews our operating results and operating plans and makes resource allocation decisions on a Company-wide or aggregate basis. We manage our operations in two reportable segments, pharmaceutical and diagnostics. The pharmaceutical segment consists of our pharmaceutical operations in Chile, Mexico, Ireland, Israel and Spain, Rayaldee product sales and our pharmaceutical research and development. The diagnostics segment primarily consists of clinical and genomics laboratory operations through BioReference and point-of-care operations. There are no significant inter-segment sales. We evaluate the performance of each segment based on operating profit or loss. There is no inter-segment allocation of interest expense or income taxes. Refer to Note 15.

Shipping and handling costs. We do not charge customers for shipping and handling costs. Shipping and handling costs are classified as Cost of revenues in the Condensed Consolidated Statement of Operations.

Foreign currency translation. The financial statements of certain of our foreign operations are measured using the local currency as the functional currency. The local currency assets and liabilities are generally translated at the rate of exchange to the U.S. dollar on the balance sheet date and the local currency revenues and expenses are translated at average rates of exchange to the U.S. dollar during the reporting periods. Foreign currency transaction gains (losses) have been reflected as a component of Other income (expense), net within the Condensed Consolidated Statement of Operations and foreign currency translation gains (losses) have been included as a component of the Condensed Consolidated Statement of Comprehensive Income (Loss). During the three and six months ended June 30, 2022, we recorded $0.8 million and $1.8 million, respectively of transaction losses. During the three and six months ended June 30, 2021, we recorded $(0.4) million and $4.4 million, respectively, of transaction gains and losses.

Variable interest entities. The consolidation of a variable interest entity (“VIE”) is required when an enterprise has a controlling financial interest. A controlling financial interest in a VIE will have both of the following characteristics: (a) the power to direct the activities of a VIE that most significantly impact the VIE’s economic performance and (b) the obligation to absorb losses of the VIE that could potentially be significant to the VIE. Refer to Note 6.

Investments. We have made strategic investments in development stage and emerging companies. We record these investments as equity method investments or as equity securities based on our percentage of ownership and whether we have significant influence over the operations of the investees. For investments classified under the equity method of accounting, we record our proportionate share of their losses in Losses from investments in investees in our Condensed Consolidated Statement of Operations. Refer to Note 6. For investments classified as equity securities, we record changes in their fair value as Other income (expense) in our Condensed Consolidated Statement of Operations based on their closing price per share at the end of each reporting period, unless the equity security does not have a readily determinable fair value. Refer to Note 6.

Recently adopted accounting pronouncements.

In August 2020, the FASB issued ASU No. 2020-06, “Debt—Debt with Conversion and Other Options (Subtopic 470-20) and Derivatives and Hedging—Contracts in Entity's Own Equity (Subtopic 815-40).” ASU 2020-06 simplifies the accounting for convertible instruments by reducing the number of accounting models for convertible debt instruments and convertible preferred stock. The ASU is effective for public entities for fiscal years beginning after December 15, 2021, with early adoption permitted. As required, we adopted ASU 2020-06 on January 1, 2022 and used the modified retrospective approach for all convertible debt instruments at the beginning of the period of adoptions. Results for reporting periods beginning January 1, 2022 are presented under ASU 2020-06, while prior period amounts were not adjusted and continue to be reported in accordance with historic accounting guidance.

Under the modified approach, entities will apply the guidance to all financial instruments that are outstanding as of the beginning of the year of adoption with the cumulative effect recognized as an adjustment to the opening balance of retained earnings. ASU 2020-06 eliminates the cash conversion and beneficial conversion feature models in ASC 470-20 that require an issuer of certain convertible debt and preferred stock to separately account for embedded conversion features as a component of equity. The adoption of ASU 2020-06 at January 1, 2022 resulted in an increase of the Convertible notes of $21.6 million, a reduction of the Accumulated deficit of $17.5 million and a reduction of Additional paid-in capital of $39.1 million.

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Earnings (Loss) Per Share

6 Months Ended

Jun. 30, 2022

Earnings Per Share [Abstract]

EARNINGS (LOSS) PER SHARE

EARNINGS (LOSS) PER SHAREBasic income (loss) per share is computed by dividing our net income (loss) by the weighted average number of shares of our Common Stock outstanding during the period. Shares of Common Stock outstanding under the share lending arrangement entered into in conjunction with the 2025 Notes (as defined in Note 7) are excluded from the calculation of basic and diluted earnings per share because the borrower of the shares is required under the share lending arrangement to refund any dividends

paid on the shares lent. Refer to Note 7. For diluted earnings per share, the dilutive impact of stock options and warrants is determined by applying the “treasury stock” method. The dilutive impact of the 2033 Senior Notes, the 2023 Convertible Notes and the 2025 Notes (each, as defined and discussed in Note 7) has been considered using the “if converted” method. For periods in which their effect would be antidilutive, no effect is given to Common Stock issuable under outstanding options or warrants or the potentially dilutive shares issuable pursuant to the 2033 Senior Notes, the 2023 Convertible Notes and the 2025 Notes in the dilutive computation.

A total of 56,605,791 and 64,292,882 potential shares of Common Stock were excluded from the calculation of diluted net loss per share for the three months ended June 30, 2022, and 2021, respectively, because their inclusion would be antidilutive. A total of 57,016,847 and 69,861,689 potential shares of Common Stock were excluded from the calculation of diluted net loss per share for the six months ended June 30, 2022, and 2021, respectively, because their inclusion would be antidilutive. A full presentation of diluted earnings per share has not been provided because the required adjustments to the numerator and denominator resulted in diluted earnings per share equivalent to basic earnings per share.

During the three months ended June 30, 2022, an aggregate of 789,063 options and warrants to purchase shares of our Common Stock were exercised, resulting in the issuance of 546,337 shares of Common Stock. Of the 789,063 options and warrants exercised, 242,726 shares of Common Stock were surrendered in lieu of a cash payment via the net exercise feature of such instruments.

During the six months ended June 30, 2022, an aggregate of 844,813 options and warrants to purchase shares of our Common Stock were exercised, resulting in the issuance of 602,087 shares of Common Stock. Of the 844,813 options and warrants exercised, 242,726 shares of Common Stock were surrendered in lieu of a cash payment via the net exercise feature of such instruments.

During the three months ended June 30, 2021, an aggregate of 63,625 options or warrants to purchase shares of our Common Stock were exercised, resulting in the issuance of 63,625 shares of Common Stock. Of the 63,625 options and warrants exercised, no shares of Common Stock were surrendered in lieu of a cash payment via the net exercise feature of such instruments.

During the six months ended June 30, 2021, an aggregate of 181,125 options or warrants to purchase shares of our Common Stock were exercised, resulting in the issuance of 181,125 shares of Common Stock. Of the 181,125 options and warrants exercised, no shares of Common Stock were surrendered in lieu of a cash payment via the net exercise feature of such instruments.

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Composition of Certain Financial Statement Captions

6 Months Ended

Jun. 30, 2022

Organization, Consolidation and Presentation of Financial Statements [Abstract]

COMPOSITION OF CERTAIN FINANCIAL STATEMENT CAPTIONS

COMPOSITION OF CERTAIN FINANCIAL STATEMENT CAPTIONS

(In thousands)	June 30, 2022		December 31, 2021
Accounts receivable, net:
Accounts receivable	$	165,226	$	261,476
Less: allowance for credit losses	(6,801)		(1,839)
	$	158,425	$	259,637
Inventories, net:
Consumable supplies	$	37,054	$	39,447
Finished products	42,321		44,107
Work in-process	1,892		1,615
Raw materials	7,256		6,112
Less: inventory reserve	(5,217)		(4,779)
	$	83,306	$	86,502
Other current assets and prepaid expenses:
Taxes recoverable	$	5,442	$	5,598
Prepaid expenses	12,324		10,641
Prepaid insurance	7,166		4,383
Other receivables	11,273		353
Other	6,358		6,195
	$	42,563	$	27,170
Intangible assets, net:
Customer relationships	$	311,864	$	314,823
Technologies	822,323		246,101
Trade names	49,735		49,770
Covenants not to compete	12,907		12,920
Licenses	5,873		5,766
Product registrations	6,440		6,995
Other	5,755		6,128
Less: accumulated amortization	(352,488)		(320,820)
	$	862,409	$	321,683
Accrued expenses:
Inventory received but not invoiced	$	18,853	$	40,446
Commitments and contingencies	12,745		27,819
Employee benefits	34,368		45,939
Contract liabilities	257		258
Clinical trials	4,245		4,867
Contingent consideration	487		487
Finance leases short-term	2,625		2,257
Professional fees	4,116		2,121
Other	50,558		69,299
	$	128,254	$	193,493

(In thousands)	June 30, 2022		December 31, 2021
Other long-term liabilities:
Contingent consideration	$	2,416	$	2,350
Mortgages and other debts payable	1,680		2,224
Finance leases long-term	4,588		2,924
Contract liabilities	192		208
Other	7,361		7,356
	$	16,237	$	15,062

Our intangible assets and goodwill relate principally to our completed acquisitions of OPKO Renal, OPKO Biologics, EirGen, BioReference and ModeX. We amortize intangible assets with definite lives on a straight-line basis over their estimated useful lives. The estimated useful lives by asset class are as follows: technologies - 7-17 years, customer relationships - 7-20 years, product registrations - 7-10 years, covenants not to compete - 5 years, trade names - 5-10 years, other 9-13 years. We do not anticipate capitalizing the cost of product registration renewals, rather we expect to expense these costs, as incurred. Our goodwill is not tax deductible for income tax purposes in any jurisdiction in which we operate.

As of December 31, 2021, GeneDx met the held-for-sale accounting criteria and its related assets and liabilities were recognized at the lower of carrying value or fair value less costs to sell in the consolidated balance sheet. In addition, at December 31, 2021, Assets held for sale included $151.8 million of goodwill related to GeneDx.

In the first quarter of 2022, we reclassified $590.0 million of IPR&D related to Somatrogon from IPR&D in our Condensed Consolidated Balance Sheet upon the approval of NGENLA (Somatrogon) in Europe and Japan. The assets will be amortized on a straight-line basis over their estimated useful life of approximately 12 years. Other changes in value of the intangible assets and goodwill during the six months ended June 30, 2022 and 2021 were primarily due to foreign currency fluctuations between the Chilean Peso, and the Euro against the U.S. dollar.

The following table summarizes the changes in Goodwill by reporting unit during the six months ended June 30, 2022.

	2022
(In thousands)	Gross goodwill at January 1		Cumulative impairment at January 1		Acquisitions and dispositions		Foreign exchange and other		Balance at June 30
Pharmaceuticals
CURNA	$	4,827	$	(4,827)			$	—	$	—
Rayaldee	86,554		—				(6,652)		79,902
FineTech	11,698		(11,698)				—		—
ModeX	—		—		65,786		—		65,786
OPKO Biologics	139,784		—				—		139,784
OPKO Chile	3,760		—				(301)		3,459
OPKO Health Europe	7,478		—				(589)		6,889
OPKO Mexico	100		(100)				—		—
Transition Therapeutics	3,421		(3,421)				—		—
Diagnostics
BioReference	434,809		—		(151,784)		—		283,025
OPKO Diagnostics	17,977		(17,977)				—		—
	$	710,408	$	(38,023)	$	(85,998)	$	(7,542)	$	578,845

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Acquisitions and Investments

6 Months Ended

Jun. 30, 2022

Business Combinations [Abstract]

ACQUISITIONS AND INVESTMENTS

ACQUISITIONS AND INVESTMENTS

ModeX Acquisition

On May 9, 2022, the Company entered into the ModeX Merger Agreement, pursuant to which ModeX survived the ModeX Merger as a wholly owned subsidiary of the Company. The Company paid the entirety of the $300.0 million purchase price pursuant to the issuance of the Consideration Shares to the former stockholders of ModeX. The Consideration Shares were valued at $219.4 million, based on the closing price per share of our Common Stock of $2.44 as reported by NASDAQ on the Closing Date. Included in the total purchase price of $221.7 million are $2.3 million of fully vested equity awards.

The following table summarizes the preliminary purchase price allocation and the estimated fair value of the net assets acquired and liabilities assumed at the date of acquisition. The purchase price allocation for the ModeX transaction is preliminary pending completion of the fair value analysis of acquired assets and liabilities:

(in thousands)	ModeX
Current assets
Cash and cash equivalents	$	218
Other assets	554
Property, plant and equipment	1,046
IPR&D assets	195,000
Goodwill	65,786
Accounts payable	(202)
Deferred tax liability	(40,740)
Total purchase price	$	221,662

Goodwill from the acquisition of ModeX principally relates to intangible assets that do not qualify for separate recognition (for instance, ModeX's assembled workforce) and the deferred tax liability generated as a result of the transaction. Goodwill is not tax deductible for income tax purposes and was assigned to the pharmaceutical reporting segment.

Our IPR&D assets will not be amortized until the underlying development programs are completed. Intangible assets are tested for impairment whenever events or changes in circumstances indicate that the carrying amount of such assets may not be recoverable, although IPR&D is required to be tested at least annually until the project is completed or abandoned. Upon obtaining regulatory approval, the IPR&D asset is then accounted for as a finite-lived intangible asset and amortized depending on pattern of future use.

Revenue and Net income (loss) in the Condensed Consolidated Statement of Operations for the six months ended June 30, 2022 includes revenue and net loss of ModeX from the date of acquisition to the six months ended June 30, 2022 of $0.0 million and $1.1 million, respectively.

Investments

The following table reflects the accounting method, carrying value and underlying equity in net assets of our unconsolidated investments as of June 30, 2022 and December 31, 2021:

(in thousands)	As of June 30, 2022				As of December 31, 2021
Investment type	Investment Carrying Value		Underlying Equity in Net Assets		Investment Carrying Value		Underlying Equity in Net Assets
Equity method investments	$	173	$	4,822	$	263	$	3,577
Variable interest entity, equity method	797		2,417		816		3,043
Equity method investments - FV option	100,800				—
Equity securities	1,508				4,226
Equity securities with no readily determinable fair value	5,396				5,408
Warrants and options	11				16
Total carrying value of investments	$	108,685			$	10,729

Equity method investments

Our equity method investments, other than Sema4 disclosed below, consist of investments in Pharmsynthez (ownership 9%), Cocrystal Pharma, Inc. (“COCP”) (3%), Non-Invasive Monitoring Systems, Inc. (“NIMS”) (1%), Neovasc, Inc. (“Neovasc”) (1%), BioCardia, Inc. (“BioCardia”) (1%), Xenetic Biosciences, Inc. (“Xenetic”) (3%), and LeaderMed Health Group Limited (“LeaderMed”) (47%). The aggregate amount of assets, liabilities, and net losses of these equity method investees as of and for the six months ended June 30, 2022 were $212.4 million, $41.7 million, and $48.6 million, respectively. The aggregate amount of assets, liabilities, and net losses of our equity method investees as of and for the year ended December 31, 2021 were $223.6 million, $37.9 million, and $69.4 million, respectively. We have determined that we and/or our related parties have the ability to exercise significant influence over our equity method investments through our board representation and/or voting power. Accordingly, we account for our investment in these entities under the equity method and record our proportionate share of their losses in Loss from investments in investees in our Condensed Consolidated Statement of Operations. The aggregate value of our equity method investments based on the quoted market prices of their respective shares of common stock and the number of shares held by us as of June 30, 2022 and December 31, 2021 was $1.9 million and $4.5 million, respectively.

Equity method investments - FV option

On April 29, 2022, the Company sold GeneDx to Sema4 in accordance with the terms of the GeneDx Merger Agreement, pursuant to which Sema4 paid to the Company aggregate consideration of $150.0 million in cash (before deduction of transaction expenses and other customary purchase price adjustments), together with the Closing Shares of Sema4 Common Stock. As of June 30, 2022, we held 80 million shares of Sema4’s Class A common stock, representing an approximate 21.2% ownership interest.

Pursuant to the GeneDx Merger Agreement, the Company designated, and Sema4 nominated for election an individual to serve on the board of directors of Sema4, and such nominee was elected by Sema4’s stockholders to serve as a director until Sema4’s 2024 annual meeting of stockholders. As a result, we have determined that the Company or our related parties can exercise significant influence over the investee through our board representation or voting power. However, our influence is restricted by the Sema4 Shareholder Agreement, pursuant to which we have agreed to vote our shares of Sema4 Common Stock in accordance with the recommendation of Sema4’s board of directors for so long as we continue to hold at least 5% of the outstanding shares of Sema4 Common Stock. Our sole ability to influence the policy-making process is through our board representation. However, because we hold only one out of eleven seats on Sema4’s board of directors, our intention is that we will no longer have a designee serving on Sema4’s board of directors upon the expiration of the Sema4 Lock-Up Period. As such, OPKO is not actively participating in the policy-making process of Sema4. We elected to we account for our investment in Sema4 under the equity method fair value option and record gains and losses from changes in fair value in other income (expense), net in our Condensed Consolidated Statement of Operations. For the three and six months ended June 30, 2022, we recognized $71.2 million in net losses for fair value changes in our Sema4 investment.

Investments in Equity Securities

Our equity securities consist of investments in Phio Pharmaceuticals (“Phio”) (ownership 0.01%), VBI Vaccines Inc. (“VBI”) (1%), ChromaDex Corporation (“ChromaDex”) (0.1%), Eloxx Pharmaceuticals, Inc. (“Eloxx”) (1%), and CAMP4 Therapeutics Corporation (“CAMP4”) (2%) and HealthSnap, Inc. (7%). We have determined that our ownership, along with

that of our related parties, does not provide us with significant influence over the operations of these investments. Accordingly, we account for our investment in these entities as equity securities, and we record changes in the fair value of these investments in Other income (expense) each reporting period when they have readily determinable fair value. Equity securities without a readily determinable fair value are adjusted to fair value when there is an observable price change. Net gains and losses on our equity securities for the six months ended June 30, 2022, and 2021 were as follows:

	For the six months ended June 30
(in thousands)	2022		2021
Equity Securities:
Net gains and losses recognized during the period on equity securities	$	(2,718)	$	1,408
Less: Net gains realized during the period on equity securities	—		(2,981)
Unrealized net gains and losses recognized during the period on equity securities still held at the reporting date	$	(2,718)	$	(1,573)

Sales of investments

Gains (losses) included in earnings from sales of our investments are recorded in Other income (expense), net in our Condensed Consolidated Statement of Operations. The cost of securities sold is based on the specific identification method.

Warrants and options

In addition to our equity method investments and equity securities, we hold options to purchase 47 thousand additional shares of BioCardia, all of which were vested as of June 30, 2022 and December 31, 2021, and 33 thousand and 0.7 million to purchase additional shares of COCP and InCellDx, respectively. We recorded the changes in the fair value of the options and warrants in Fair value changes of derivative instruments, net in our Condensed Consolidated Statement of Operations. We also recorded the fair value of the options and warrants in Investments, net in our Condensed Consolidated Balance Sheet. See further discussion of the Company’s options and warrants in Note 9 and Note 10.

Investments in variable interest entities

We have determined that we hold variable interests in LeaderMed and Zebra Biologics, Inc. (“Zebra”). We made this determination as a result of our assessment that they do not have sufficient resources to carry out their principal activities without additional financial support.

On September 14, 2021, we and LeaderMed, a pharmaceutical development company with operations based in Asia, announced the formation of a joint venture to develop, manufacture and commercialize two of OPKO’s clinical stage, long-acting drug products in Greater China and eight other Asian territories. Under the terms of the agreements, we have granted the joint venture exclusive rights to develop, manufacture and commercialize (a) OPK88003, an oxyntomodulin analog being developed for the treatment of obesity and diabetes, and (b) Factor VIIa-CTP, a novel long acting coagulation factor being developed to treat hemophilia, in exchange for 4,703 shares 47% ownership interest in the joint venture. In addition, we received an upfront payment of $1.0 million and will be reimbursed for clinical trial material and technical support we provide the joint venture.

In order to determine the primary beneficiary of the joint venture, we evaluated our investment and our related parties’ investment, as well as our investment combined with the related parties’ investment to identify if we had the power to direct the activities that most significantly impact the economic performance of the joint venture. Based on the capital structure, governing documents and overall business operations of the joint venture, we determined that, while a VIE, we do not have the power to direct the activities that most significantly impact the joint venture’s economic performance and do not have an obligation to fund expected losses. We did determine that we can significantly influence control of the joint venture through our board representation and voting power. Therefore, we have the ability to exercise significant influence over the joint venture’s operations and account for our investment in the joint venture under the equity method.

We own 1,260,000 shares of Zebra Series A-2 Preferred Stock and 900,000 shares of Zebra restricted common stock (ownership 29% at June 30, 2022). Zebra is a privately held biotechnology company focused on the discovery and development of biosuperior antibody therapeutics and complex drugs. Dr. Richard Lerner, M.D., a former member of our Board of Directors, is a founder of Zebra and, along with Dr. Frost, serves as a member of Zebra’s Board of Directors.

In order to determine the primary beneficiary of Zebra, we evaluated our investment and our related parties’ investment, as well as our investment combined with the related parties’ investment to identify if we had the power to direct the activities that most significantly impact the economic performance of Zebra. Based on the capital structure, governing documents and

overall business operations of Zebra, we determined that, while a VIE, we do not have the power to direct the activities that most significantly impact Zebra’s economic performance and have no obligation to fund expected losses. We determined, however, that we can significantly influence control of Zebra through our board representation and voting power. Therefore, we have the ability to exercise significant influence over Zebra’s operations and account for our investment in Zebra under the equity method.

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Debt

6 Months Ended

Jun. 30, 2022

Debt Disclosure [Abstract]

DEBT

DEBT    

As of June 30, 2022 and December 31, 2021, our debt consisted of the following:

(In thousands)	June 30, 2022		December 31, 2021
2025 Notes	$	141,537	$	119,360
2023 Convertible Notes	66,889		65,525
2033 Senior Notes	3,050		3,050
JP Morgan Chase	2,867		—
Chilean and Spanish lines of credit	15,351		13,672
Current portion of notes payable	771		1,022
Long term portion of notes payable	1,984		2,642
Total	$	232,449	$	205,272
Balance sheet captions
Convertible Notes	$	211,477	$	187,935
Current portion of lines of credit and notes payable	18,989		14,695
LT notes payable included in long-term liabilities	1,984		2,642
Total	$	232,449	$	205,272

In February 2019, we issued $200.0 million aggregate principal amount of Convertible Senior Notes due 2025 (the “2025 Notes”) in an underwritten public offering. The 2025 Notes bear interest at a rate of 4.50% per year, payable semiannually in arrears on February 15 and August 15 of each year. The notes mature on February 15, 2025, unless earlier repurchased, redeemed or converted.

Holders may convert their 2025 Notes into shares of Common Stock at their option at any time prior to the close of business on the business day immediately preceding November 15, 2024 only under the following circumstances: (1) during any calendar quarter commencing after the calendar quarter ended March 31, 2019 (and only during such calendar quarter), if the last reported sale price of our Common Stock for at least 20 trading days (whether or not consecutive) during a period of 30 consecutive trading days ending on the last trading day of the immediately preceding calendar quarter is greater than or equal to 130% of the conversion price on each applicable trading day; (2) during the five business day period after any five consecutive trading day period (the “measurement period”) in which the trading price per $1,000 principal amount of 2025 Notes for each trading day of the measurement period was less than 98% of the product of the last reported sale price of our Common Stock and the conversion rate on each such trading day; (3) if we call any or all of the 2025 Notes for redemption, at any time prior to the close of business on the scheduled trading day immediately preceding the redemption date; or (4) upon the occurrence of specified corporate events set forth in the indenture governing the 2025 Notes. On or after November 15, 2024, until the close of business on the business day immediately preceding the maturity date, holders of the 2025 Notes may convert their notes at any time, regardless of the foregoing conditions. Upon conversion, we will pay or deliver, as the case may be, cash, shares of our Common Stock, or a combination of cash and shares of our Common Stock, at our election.

The initial and current conversion rate for the 2025 Notes is 236.7424 shares of Common Stock per $1,000 principal amount of 2025 Notes (equivalent to a conversion price of approximately $4.22 per share of Common Stock). The conversion rate for the 2025 Notes is subject to adjustment in certain events but will not be adjusted for any accrued and unpaid interest. In addition, following certain corporate events that occur prior to the maturity date of the 2025 Notes or if we deliver a notice of redemption, in certain circumstances the indenture governing the 2025 Notes requires an increase in the conversion rate of the 2025 Notes for a holder who elects to convert its notes in connection with such a corporate event or notice of redemption, as the case may be.

We may not redeem the 2025 Notes prior to February 15, 2022. We may redeem for cash any or all of the 2025 Notes, at our option, on or after February 15, 2022, if the last reported sale price of our Common Stock has been at least 130% of the then current conversion price for the notes for at least 20 trading days (whether or not consecutive) during any 30 consecutive trading day period (including the last trading day of such period) ending on, and including, the trading day immediately preceding the date on which we provide notice of redemption at a redemption price equal to 100% of the principal amount of the notes to be redeemed, plus accrued and unpaid interest to, but excluding, the redemption date. No sinking fund is provided for the 2025 Notes.

If we undergo a fundamental change, as defined in the indenture governing the 2025 Notes, prior to the maturity date of the 2025 Notes, holders may require us to repurchase for cash all or any portion of their notes at a repurchase price equal to 100% of the principal amount of the notes to be repurchased, plus accrued and unpaid interest to, but excluding, the fundamental change repurchase date. The 2025 Notes are our senior unsecured obligations and rank senior in right of payment to any of our indebtedness that is expressly subordinated in right of payment to the 2025 Notes; equal in right of payment to any of our existing and future liabilities that are not so subordinated; effectively junior in right of payment to any of our secured indebtedness to the extent of the value of the assets securing such indebtedness; and structurally junior to all indebtedness and other liabilities (including trade payables) of our current or future subsidiaries.

In May 2021, we entered into exchange agreements with certain holders of the 2025 Notes, pursuant to which the holders exchanged $55.4 million in aggregate principal amount of the outstanding 2025 Notes for 19,051,270 shares of our Common Stock (the “Exchange”). We recorded an $11.1 million non-cash loss related to the Exchange during the second quarter of 2021.

In conjunction with the issuance of the 2025 Notes, we agreed to loan up to 30,000,000 shares of our Common Stock to affiliates of the underwriter in order to assist investors in the 2025 Notes to hedge their position. Following consummation of the Exchange, the number of outstanding borrowed shares of Common Stock was reduced by approximately 8,105,175 shares. As of June 30, 2022 and December 31, 2021, a total of 21,144,825 and 21,144,825 shares remained outstanding under the share lending arrangement, respectively. We will not receive any of the proceeds from the sale of the borrowed shares, but we received a one-time nominal fee of $0.3 million for the newly issued shares. Shares of our Common Stock outstanding under the share lending arrangement are excluded from the calculation of basic and diluted earnings per share. See Note 4.

The following table sets forth information related to the 2025 Notes which is included in our Condensed Consolidated Balance Sheet as of June 30, 2022:

(In thousands)	2025 Senior Notes		Discount		Debt Issuance Cost		Total
Balance at December 31, 2021	$	144,580	$	(22,747)	$	(2,473)	$	119,360
Amortization of debt discount and debt issuance costs	—		—		534		534
Adoption of ASU 2020-06	$	—	$	22,747	$	(1,104)	$	21,643
Balance at June 30, 2022	$	144,580	$	—	$	(3,043)	$	141,537

In August 2020, the FASB issued ASU No. 2020-06, “Debt—Debt with Conversion and Other Options (Subtopic 470-20) and Derivatives and Hedging—Contracts in Entity's Own Equity (Subtopic 815-40).” ASU 2020-06 simplifies the accounting for convertible instruments by reducing the number of accounting models for convertible debt instruments and convertible preferred stock. The ASU is effective for public entities for fiscal years beginning after December 15, 2021, with early adoption permitted. As required, we adopted ASU 2020-06 on January 1, 2022 and used the modified retrospective approach for all convertible debt instruments at the beginning of the period of adoptions. Results for reporting periods beginning January 1, 2022 are presented under ASU 2020-06, while prior period amounts were not adjusted and continue to be reported in accordance with historic accounting guidance.

Under the modified approach, entities will apply the guidance to all financial instruments that are outstanding as of the beginning of the year of adoption with the cumulative effect recognized as an adjustment to the opening balance of retained earnings. ASU 2020-06 eliminates the cash conversion and beneficial conversion feature models in ASC 470-20 that require an issuer of certain convertible debt and preferred stock to separately account for embedded conversion features as a component of equity. The adoption of ASU 2020-06 at January 1, 2022 resulted in an increase of the Convertible notes of $21.6 million, a reduction of the Accumulated deficit of $17.5 million and a reduction of Additional paid-in capital of $39.1 million.

In February 2018, we issued a series of 5% Convertible Promissory Notes (the “2023 Convertible Notes”) in the aggregate principal amount of $55.0 million. The 2023 Convertible Notes mature five years following the date of issuance. Each holder of a 2023 Convertible Note has the option, from time to time, to convert all or any portion of the outstanding principal balance of such 2023 Convertible Note, together with accrued and unpaid interest thereon, into shares of our Common

Stock at a conversion price of $5.00 per share. We may redeem all or any part of the then issued and outstanding 2023 Convertible Notes, together with accrued and unpaid interest thereon, pro rata among the holders, upon no fewer than 30 days, and no more than 60 days, notice to the holders. The 2023 Convertible Notes contain customary events of default and representations and warranties of OPKO.

Purchasers of the 2023 Convertible Notes included an affiliate of Dr. Phillip Frost, M.D., our Chairman and Chief Executive Officer, and Dr. Jane H. Hsiao, Ph.D., MBA, our Vice-Chairman and Chief Technical Officer.

In January 2013, we entered into note purchase agreements with respect to the issuance and sale of our 3.0% Senior Notes due 2033 (the “2033 Senior Notes”) in a private placement exempt from registration under the Securities Act. We issued the 2033 Senior Notes on January 30, 2013. The 2033 Senior Notes, which totaled $175.0 million in original principal amount, bear interest at the rate of 3.0% per year, payable semiannually on February 1 and August 1 of each year. The 2033 Senior Notes mature on February 1, 2033, unless earlier repurchased, redeemed or converted. Upon a fundamental change, as defined in the indenture governing the 2033 Senior Notes, subject to certain exceptions, the holders may require us to repurchase all or any portion of their 2033 Senior Notes for cash at a repurchase price equal to 100% of the principal amount of the 2033 Senior Notes being repurchased, plus any accrued and unpaid interest to, but not including, the related fundamental change repurchase date.

From 2013 to 2016, holders of the 2033 Senior Notes converted $143.2 million in aggregate principal amount into an aggregate of 21,539,873 shares of Common Stock. On February 1, 2019, approximately $28.8 million aggregate principal amount of 2033 Senior Notes were tendered by holders pursuant to such holders’ option to require us to repurchase the 2033 Senior Notes as set forth in the indenture, governing the 2033 Senior Notes, following which repurchase only $3.0 million aggregate principal amount of the 2033 Senior Notes remained outstanding. Holders of the remaining $3.0 million principal amount of the 2033 Senior Notes may require us to repurchase such notes for 100% of their principal amount, plus accrued and unpaid interest, on February 1, 2023, on February 1, 2028, or following the occurrence of a fundamental change as described above.

The terms of the 2033 Senior Notes, include, among others: (i) rights to convert the notes into shares of our Common Stock, including upon a fundamental change; and (ii) a coupon make-whole payment in the event of a conversion by the holders of the 2033 Senior Notes on or after February 1, 2017 but prior to February 1, 2019. We determined that these specific terms were embedded derivatives. Embedded derivatives are required to be separated from the host contract, the 2033 Senior Notes, and carried at fair value when: (a) the embedded derivative possesses economic characteristics that are not clearly and closely related to the economic characteristics of the host contract; and (b) a separate, stand-alone instrument with the same terms would qualify as a derivative instrument. We concluded that the embedded derivatives within the 2033 Senior Notes met these criteria and, as such, were valued separate and apart from the 2033 Senior Notes and recorded at fair value each reporting period.

For accounting and financial reporting purposes, we combined these embedded derivatives and valued them together as one unit of accounting. In 2017, certain terms of the embedded derivatives expired pursuant to the original agreement and the embedded derivatives no longer met the criteria to be separated from the host contract and, as a result, the embedded derivatives were no longer required to be valued separate and apart from the 2033 Senior Notes and were reclassified to additional paid in capital.

In November 2015, BioReference and certain of its subsidiaries entered into a credit agreement with JPMorgan Chase Bank, N.A. (“CB”), as lender and administrative agent, as amended (the “Credit Agreement”). As amended, the Credit Agreement provides for a $75.0 million secured revolving credit facility and includes a $20.0 million sub-facility for swingline loans and a $20.0 million sub-facility for the issuance of letters of credit.

The Credit Agreement is guaranteed by all of BioReference’s domestic subsidiaries and is also secured by substantially all assets of BioReference and its domestic subsidiaries, as well as a non-recourse pledge by us of our equity interest in BioReference. Availability under the Credit Agreement is based on a borrowing base composed of eligible accounts receivables of BioReference and certain of its subsidiaries, as specified therein. As of June 30, 2022, $53.1 million remained available for borrowing under the Credit Agreement. Principal under the Credit Agreement is due upon maturity on August 30, 2024.

At BioReference’s option, borrowings under the Credit Agreement (other than swingline loans) bear interest at (i) the CB floating rate (defined as the higher of (a) the prime rate and (b) the LIBOR rate (adjusted for statutory reserve requirements for Eurocurrency liabilities) for an interest period of one month plus 2.50%) plus an applicable margin of 0.75% or (ii) the LIBOR rate (adjusted for statutory reserve requirements for Eurocurrency liabilities) plus an applicable margin of 1.75%. Swingline loans will bear interest at the CB floating rate plus the applicable margin. The Credit Agreement also calls for other customary

fees and charges, including an unused commitment fee of 0.375% if the average quarterly availability is 50% or more of the revolving commitment, or 0.25% if the average quarterly availability is less than or equal to 50% of the revolving commitments.

As of June 30, 2022 and December 31, 2021, $2.9 million and no amount, respectively, was outstanding under the Credit Agreement.

The Credit Agreement contains customary covenants and restrictions, including, without limitation, covenants that require BioReference and its subsidiaries to maintain a minimum fixed charge coverage ratio if availability under the new credit facility falls below a specified amount and to comply with laws and restrictions on the ability of BioReference and its subsidiaries to incur additional indebtedness or to pay dividends and make certain other distributions to the Company, subject to certain exceptions as specified therein. Failure to comply with these covenants would constitute an event of default under the Credit Agreement, notwithstanding the ability of BioReference to meet its debt service obligations. The Credit Agreement also includes various customary remedies for the lenders following an event of default, including the acceleration of repayment of outstanding amounts under the Credit Agreement and execution upon the collateral securing obligations under the Credit Agreement. Substantially all the assets of BioReference and its subsidiaries are restricted from sale, transfer, lease, disposal or distributions to the Company, subject to certain exceptions. As of June 30, 2022, BioReference and its subsidiaries had net assets of approximately $680.0 million, which included goodwill of $283.0 million and intangible assets of $195.9 million.

On April 29, 2022, the Credit Agreement was amended to, among other things, (i) waive specified defaults under the Credit Agreement resulting from certain internal reorganization transactions that resulted in both BioReference and GeneDx changing their respective forms of organization from New Jersey corporations to Delaware limited liability companies, (ii) provide for the disposition of GeneDx pursuant to the transactions contemplated by the GeneDx Merger Agreement, (iii) amend certain reporting requirements under the Credit Agreement and (iv) provide that the borrowers under the Credit Agreement may effect certain restricted payments to the extent necessary for their parent entities to pay income tax in respect of income earned by the borrowers.

In addition to the Credit Agreement, we had line of credit agreements with thirteen other financial institutions as of June 30, 2022 and eleven other financial institutions as of December 31, 2021 in the U.S., Chile and Spain. These lines of credit are used primarily as sources of working capital for inventory purchases.

The following table summarizes the amounts outstanding under the BioReference, Chilean and Spanish lines of credit:

(Dollars in thousands)				Balance Outstanding
Lender	Interest rate on borrowings at June 30, 2022	Credit line capacity		June 30, 2022		December 31, 2021
JPMorgan Chase	3.25%	$	75,000	$	2,867	$	—
Itau Bank	5.50%	1,900		1,293		1,603
Bank of Chile	6.60%	2,500		1,452		1,048
BICE Bank	5.50%	2,500		1,499		850
Scotiabank	5.00%	5,500		1,560		567
Santander Bank	5.50%	5,000		2,467		503
Security Bank	5.50%	1,400		2		1,111
Estado Bank	5.50%	4,000		2,682		2,540
BCI Bank	5.00%	2,500		2,400		2,515
Corpbanca	5.00%	—		—		2,935
International Bank	5.50%	1,500		845		—
Consoorcio Bank	5.00%	2,000		1,151		—
Banco De Sabadell	1.75%	522		—		—
Santander Bank	2.15%	522		—		—
Total		$	104,844	$	18,218	$	13,672

For both June 30, 2022 and December 31, 2021, the weighted average interest rate on our lines of credit was approximately 5.4%.

At June 30, 2022 and December 31, 2021, we had notes payable and other debt (excluding the 2033 Senior Notes, the 2023 Convertible Notes, the 2025 Notes, the Credit Agreement and amounts outstanding under lines of credit described above) as follows:

(In thousands)	June 30, 2022		December 31, 2021
Current portion of notes payable	$	771	$	1,022
Other long-term liabilities	1,984		2,642
Total	$	2,755	$	3,664

The notes and other debt mature at various dates ranging from 2022 through 2026, bearing variable interest rates from 0.7% up to 3.8%. The weighted average interest rate on the notes and other debt was 1.5% on both June 30, 2022 and December 31, 2021. The notes are partially secured by our office space in Barcelona.

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Accumulated Other Comprehensive Loss

6 Months Ended

Jun. 30, 2022

Equity [Abstract]

ACCUMULATED OTHER COMPREHENSIVE LOSS

ACCUMULATED OTHER COMPREHENSIVE LOSS

For the six months ended June 30, 2022, changes in Accumulated other comprehensive loss, net of tax, were as follows:

(In thousands)	Foreign currency translation
Balance at December 31, 2021	$	(30,495)
Other comprehensive loss	(18,676)
Balance at June 30, 2022	$	(49,171)

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Fair Value Measurements

6 Months Ended

Jun. 30, 2022

Fair Value Disclosures [Abstract]

FAIR VALUE MEASUREMENTS

FAIR VALUE MEASUREMENTS

We record fair values at an exit price, representing the amount that would be received to sell an asset or paid to transfer a liability in an orderly transaction between market participants. As such, fair value is a market-based measurement determined based on assumptions that market participants would use in pricing an asset or liability. We utilize a three-tier fair value hierarchy, which prioritizes the inputs used in measuring fair value. These tiers are: Level 1, defined as observable inputs such as quoted prices in active markets; Level 2, defined as inputs other than quoted prices in active markets that are either directly or indirectly observable; and Level 3, defined as unobservable inputs in which little or no market data exists, therefore requiring an entity to develop its own assumptions.

As of June 30, 2022, we had equity securities and an equity method fair value option (refer to Note 6), forward foreign currency exchange contracts for inventory purchases (refer to Note 10) and contingent consideration related to the acquisitions of CURNA, OPKO Diagnostics and OPKO Renal that are required to be measured at fair value on a recurring basis. In addition, in connection with our investment and our consulting agreement with BioCardia, we record the related BioCardia options at fair value as well as the warrants from COCP.

Our financial assets and liabilities measured at fair value on a recurring basis are as follows:

	Fair value measurements as of June 30, 2022
(In thousands)	Quoted prices in active markets for identical assets (Level 1)		Significant other observable inputs (Level 2)		Significant unobservable inputs (Level 3)		Total
Assets:
Money market funds	$	131,658	$	—	$	—	$	131,658
Equity securities	1,508		—		—		1,508
Equity Method - FV option	100,800		—		—		100,800
Common stock options/warrants	—		11		—		11
Forward contracts	—		434		—		434
Total assets	$	233,966	$	445	$	—	$	234,411
Liabilities:
Contingent consideration	—		—		2,903		2,903
Total liabilities	$	—	$	—	$	2,903	$	2,903

	Fair value measurements as of December 31, 2021
(In thousands)	Quoted prices in active markets for identical assets (Level 1)		Significant other observable inputs (Level 2)		Significant unobservable inputs (Level 3)		Total
Assets:
Equity securities	$	4,226	$	—	$	—	$	4,226
Common stock options/warrants	—		16		—		16
Forward contracts	—		122		—		122
Total assets	$	4,226	$	138	$	—	$	4,364
Liabilities:
Contingent consideration	—		—		2,837		2,837
Total liabilities	$	—	$	—	$	2,837	$	2,837

The carrying amount and estimated fair value of our 2025 Notes, as well as the applicable fair value hierarchy tiers, are contained in the table below. The fair value of the 2025 Notes is determined using inputs other than quoted prices in active markets that are directly observable.

	June 30, 2022
(In thousands)	Carrying Value		Total Fair Value		Level 1		Level 2		Level 3
2025 Notes	$	141,537	$	145,163	$	—	$	145,163	$	—

There have been no transfers between Level 1 and Level 2 and no transfers to or from Level 3 of the fair value hierarchy.

As of June 30, 2022 and December 31, 2021, the carrying value of our other financial instrument assets approximates their fair value due to their short-term nature or variable rate of interest.

The following table reconciles the beginning and ending balances of our Level 3 assets and liabilities as of June 30, 2022:

	June 30, 2022
(In thousands)	Contingent consideration
Balance at December 31, 2021	$	2,837
Change in fair value:
Included in results of operations	69
Foreign currency impact	(3)
Balance at June 30, 2022	$	2,903

The estimated fair values of our financial instruments have been determined by using available market information and what we believe to be appropriate valuation methodologies. We use the following methods and assumptions in estimating fair value:

Contingent consideration – We estimate the fair value of the contingent consideration utilizing a discounted cash flow model for the expected payments based on estimated timing and expected revenues. We use several discount rates depending on each type of contingent consideration related to OPKO Diagnostics, CURNA and OPKO Renal transactions. As of June 30, 2022, of the $2.9 million of contingent consideration, $0.5 million was recorded in Accrued expenses and $2.4 million was recorded in Other long-term liabilities. As of December 31, 2021, of the $2.8 million of contingent consideration, $0.5 million was recorded in Accrued expenses and $2.3 million was recorded in Other long-term liabilities. As a result of our execution of the CAMP4 Agreement (as defined in Note 14), we will have to pay a percentage of any payments received under the CAMP4 Agreement to the former CURNA stockholders.

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Derivative Contracts

6 Months Ended

Jun. 30, 2022

Derivative Instruments and Hedging Activities Disclosure [Abstract]

DERIVATIVE CONTRACTS

DERIVATIVE CONTRACTS

The following table summarizes the fair values and the presentation of our derivative financial instruments in the Condensed Consolidated Balance Sheets:

(In thousands)	Balance Sheet Component	June 30, 2022		December 31, 2021
Derivative financial instruments:
Common Stock options/warrants	Investments, net	$	11	$	16
Forward contracts	Unrealized gains on forward contracts are recorded in Other current assets and prepaid expenses. Unrealized (losses) on forward contracts are recorded in Accrued expenses.	$	434	$	122

We enter into foreign currency forward exchange contracts with respect to the risk of exposure to exchange rate differences arising from inventory purchases on letters of credit. Under these forward contracts, for any rate above or below the fixed rate, we receive or pay the difference between the spot rate and the fixed rate for the given amount at the settlement date.

To qualify the derivative instrument as a hedge, we are required to meet strict hedge effectiveness and contemporaneous documentation requirements at the initiation of the hedge and assess the hedge effectiveness on an ongoing basis over the life of the hedge. At June 30, 2022 and December 31, 2021, our derivative financial instruments did not meet the documentation requirements to be designated as hedges. Accordingly, we recognize the changes in Fair value of derivative instruments, net in our Condensed Consolidated Statement of Operations. The following table summarizes the losses and gains recorded for the three and six months ended June 30, 2022 and 2021:

	Three months ended June 30,				Six months ended June 30,
(In thousands)	2022		2021		2022		2021
Derivative gain (loss):
Common Stock options/warrants	$	(4)	$	(26)	$	(5)	$	(6)
Forward contracts	342		(246)		211		(705)
Total	$	338	$	(272)	$	206	$	(711)

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Related Party Transactions

6 Months Ended

Jun. 30, 2022

Related Party Transactions [Abstract]

RELATED PARTY TRANSACTIONS

RELATED PARTY TRANSACTIONS

In August 2020, GeneDx entered into an agreement with Mednax Services, Inc. (“Mednax Services”), a subsidiary of MEDNAX, Inc., (“MEDNAX”) pursuant to which the parties formed a joint venture under the brand Detect Genomix. GeneDx’s initial capital investment in Detect Genomix was $245,000 for which GeneDx received a 49% ownership interest in Detect Genomix, and Mednax Services contributed $255,000 in exchange for a 51% ownership interest in Detect Genomix. Adam Logal, the Company’s CFO, was the chair and sat on the Board of Managers of the joint venture. Mednax Services provided administrative services to the joint venture pursuant to an administrative services agreement. GeneDx provided laboratory services to the joint venture. Dr. Roger Medel, a director of the Company, is the former Chief Executive Officer of MEDNAX and Mednax Services. Dr. Medel continues to serve on the board of MEDNAX. The joint venture was dissolved in January 2022.

On April 29, 2022, upon consummation of the GeneDx Transaction, the Company entered into a Transition Services Agreement, dated as of April 29, 2022 (the “Transition Services Agreement”), with GeneDx (now a wholly owned subsidiary of Sema4), pursuant to which OPKO has agreed to provide, at cost, certain customary support services in respect of GeneDx’s business through December 31, 2022, subject to certain limited exceptions, with such services being in order to facilitate the GeneDx Transactions, including human resources, information technology support, and finance and accounting. As of June 30, 2022, the Company had incurred aggregate expenses of $335.3 thousand for services rendered under the Transition Services Agreement, for which the Company has an offsetting receivable of $167.2 thousand payable to the Company by GeneDx in accordance with the terms of the Transition Services Agreement.

The Company owns approximately 9% of Pharmsynthez and Pharmsynthez is Xenetic’s largest and controlling stockholder. Dr. Richard Lerner, a director of the Company until his death on December 2, 2021, was a co-inventor of Xenetic’s technology and received 31,240 shares of Xenetic upon the closing of the Xenetic transactions described above. Adam Logal, our Senior Vice President and Chief Financial Officer, is a director of Xenetic.

We hold investments in Zebra (ownership 29%), Neovasc (1%), ChromaDex Corporation (0.1%), COCP (3%), NIMS (1%), Eloxx (1%), BioCardia (1%) and LeaderMed Health Group Limited (47%). These investments were considered related party transactions as a result of our executive management’s ownership interests and/or board representation in these entities. See further discussion of our investments in Note 6.

We lease office space from Frost Real Estate Holdings, LLC (“Frost Holdings”) in Miami, Florida, where our principal executive offices are located. Effective August 1, 2019, we entered into an amendment to our lease agreement with Frost Holdings. The lease, as amended, is for approximately 29,500 square feet of space. The lease provides for payments of approximately $89 thousand per month in the first year increasing annually to $101 thousand per month in the fifth year, plus applicable sales tax. The rent is inclusive of operating expenses, property taxes and parking.

Dr. Elias Zerhouni, our Vice Chairman and President, sits on the board of directors of Danaher Corporation (“Danaher”). Our subsidiary, BioReference, routinely procures products and services from several subsidiaries of Danaher, including Beckman Coulter, Integrated DNA Technologies Inc., and Leica Microsystems Inc., to which BioReference has paid $1.7 million, $0.1 million, and $0.3 million, respectively, through June 30, 2022.

BioReference purchases and uses certain products acquired from InCellDx, a company in which we hold a 29% minority interest.

We reimburse Dr. Frost for Company-related use by Dr. Frost and our other executives of an airplane owned by a company that is beneficially owned by Dr. Frost. We reimburse Dr. Frost for out-of-pocket operating costs for the use of the airplane by Dr. Frost or Company executives for Company-related business. We do not reimburse Dr. Frost for personal use of the airplane by Dr. Frost or any other executive. For the three and six months ended June 30, 2022, we reimbursed approximately $0 thousand and $30 thousand, respectively, for Company-related travel by Dr. Frost and other OPKO executives. For the three and six months ended June 30, 2021, we reimbursed approximately $0 thousand and $43 thousand, respectively, for Company-related travel by Dr. Frost and other OPKO executives.

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Commitments and Contingencies

6 Months Ended

Jun. 30, 2022

Commitments and Contingencies Disclosure [Abstract]

COMMITMENTS AND CONTINGENCIES

COMMITMENTS AND CONTINGENCIES

In connection with our acquisitions of CURNA, OPKO Diagnostics and OPKO Renal, we agreed to pay future consideration to the sellers upon the achievement of certain events. As a result, as of June 30, 2022, we recorded $2.9 million as contingent consideration, with $0.5 million recorded within Accrued expenses and $2.4 million recorded within Other long-term liabilities in the accompanying Condensed Consolidated Balance Sheets. Refer to Note 5 and Note 17.

On March 1, 2019, the Company received a Civil Investigative Demand (“CID”) from the U.S. Department of Justice (“DOJ”), Washington, DC. The CID sets forth document requests and interrogatories in connection with allegations that the Company and certain of its affiliates violated the False Claims Act and/or the Anti-Kickback Statute. On January 13, 2022, the Federal Government notified the U.S.D.C., Middle District Florida, Jacksonville Division, that it is declining to intervene in the matter but retains the right, via the Attorney General, to consent to any proposed dismissal of the action by the Court. On February 9, 2022, the States of Florida, Georgia, and Commonwealth of Massachusetts notified the U.S.D.C., Middle District Florida, Jacksonville Division, that they are declining to intervene in the matter. Notwithstanding the above declinations, on February 17, 2022, the Company was served with the Relator’s Summons and Complaint (“Complaint”), which had been previously sealed. The complaint alleges violations of the False Claims Act, the California Fraud Preventions Act, the Florida False Claims Act, the Massachusetts False Claims Act, the Georgia False Medicaid Claims Act, and illegal kickbacks. The Company is reviewing and assessing the allegations made in the Complaint and, at this point, has not determined whether there is any merit to these claims nor can it determine the extent of any potential liability. While management cannot predict the outcome of these matters at this time, the ultimate outcome could be material to our business, financial condition, results of operations, and cash flows.

As previously reported, BioReference receives and is routinely required to respond to CIDs in the ordinary course of business. On November 26, 2019, BioReference received a CID from the DOJ. The CID stated that the DOJ was investigating whether BioReference paid unlawful remuneration to health care practitioners in violation of the Anti-Kickback Statute or Stark law and thus submitted or caused to be submitted false claims to government health care programs in violation of the False Claims Act. The time period covered by the DOJ’s requests was January 1, 2011 through November 26, 2019. BioReference has fully cooperated with the DOJ by submitting the requested information and making current employees available for interviews, and the DOJ made a presentation to BioReference regarding its position. The parties have reached an agreement on the settlement amount, which is approximately $10 million, excluding attorney fees (refer to Note 17). As of June 30, 2022 and December 31, 2021, $10.5 million and $10.0 million was recorded in Accrued expenses, respectively.

On April 8, 2019, MabVax Therapeutics Holdings, Inc. filed a lawsuit in the Superior Court of California, County of San Diego against a number of individuals and entities, including the Company, Dr. Frost, Steven Rubin, the Company’s Executive Vice President-Administration, and an entity affiliated with Dr. Frost, based on the allegations raised in the SEC Complaint. The lawsuit seeks an award for actual and punitive damages, pre- and post-judgment interest; that the defendants be required to make full disclosure and accounting of their interests and transactions in plaintiff’s securities; costs of the suit, and reasonable attorney’s fees; and such other legal and equitable relief as the Court may deem proper under the circumstances. On January 31, 2022, plaintiffs entered into a confidential mutual release and settlement agreement with the Company, Dr. Frost, Frost Gamma Investment Trust, and Steve Rubin, which has been approved by the United States Bankruptcy Court for the District of Delaware.

On April 5, 2019, former shareholders of Claros Diagnostics, Inc. filed a complaint in the Chancery Court of Delaware against the Company, alleging among other things, that the Company breached the Agreement and Plan of Merger dated October 13, 2011 by and among the Company, Claros Merger Subsidiary, LLC and Claros Diagnostics, Inc. (the “Claros Merger Agreement”): (i) by failing to make a milestone payment of $2.375 million (payable in OPKO Common Stock) upon obtaining FDA approval of the Claros PSA test; and (ii) by repudiating its obligations to make additional future milestone payments as required under the Claros Merger Agreement. In January 2021, the Company and the shareholder representative entered into a settlement agreement providing, among other things, that the Company pay the shareholders $1.2 million, which the Company has paid in full.

In April 2017, the Civil Division of the United States Attorney’s Office for the Southern District of New York (the “SDNY”) informed BioReference that it believed that, from 2008 to 2012, BioReference had, in violation of the False Claims Act, improperly billed Medicare and TRICARE (both are federal government healthcare programs) for clinical laboratory services provided to hospital inpatient beneficiaries at certain hospitals. In April 2019, the SDNY also informed BioReference that it believed that BioReference provided physicians subsidies for electronic health record systems prior to 2012 that violated regulations adopted by HHS in 2006 which allowed laboratories to provide these donations under certain conditions. BioReference and the SDNY reached a settlement with respect to these matters and a final settlement and release, including BioReference’s payment of an approximately $11.5 million settlement amount, was approved on September 22, 2020. The settlement amount has been paid. The amount of relator attorneys’ fees is currently being negotiated.

From time to time, we may receive inquiries, document requests, CIDs or subpoenas from the Department of Justice, OCR, CMS, various payors and fiscal intermediaries, and other state and federal regulators regarding investigations, audits and reviews. In addition to the matters discussed in this note, we are currently responding to CIDs, subpoenas, payor audits, and document requests for various matters relating to our laboratory operations. Some pending or threatened proceedings against us may involve potentially substantial amounts as well as the possibility of civil, criminal, or administrative fines, penalties, or other sanctions, which could be material. Settlements of suits involving the types of issues that we routinely confront may require monetary payments as well as corporate integrity agreements. Additionally, qui tam or “whistleblower” actions initiated under the civil False Claims Act may be pending but placed under seal by the court to comply with the False Claims Act’s requirements for filing such suits. Also, from time to time, we may detect issues of non-compliance with federal healthcare laws pertaining to claims submission and reimbursement practices and/or financial relationships with physicians, among other things. We may avail ourselves of various mechanisms to address these issues, including participation in voluntary disclosure protocols. Participating in voluntary disclosure protocols can have the potential for significant settlement obligations or even enforcement action. The Company generally has cooperated, and intends to continue to cooperate, with appropriate regulatory authorities as and when investigations, audits and inquiries arise.

We are a party to other litigation in the ordinary course of business. While we cannot predict the ultimate outcome of legal matters, we accrue a liability for legal contingencies when we believe that it is both probable that a liability has been incurred and that we can reasonably estimate the amount of the loss. It’s reasonably possible the ultimate liability could exceed amounts currently estimated and we review established accruals and adjust them to reflect ongoing negotiations, settlements, rulings, advice of legal counsel and other relevant information. To the extent new information is obtained and our views on the probable outcomes of claims, suits, assessments, investigations or legal proceedings change, changes in our accrued liabilities would be recorded in the period in which such determination is made. Because of the high degree of judgment involved in establishing loss estimates, the ultimate outcome of such matters will differ from our estimates and such differences may be material to our business, financial condition, results of operations, and cash flows.

At June 30, 2022, we were committed to make future purchases for inventory and other items in 2022 that occur in the ordinary course of business under various purchase arrangements with fixed purchase provisions aggregating approximately $197.2 million.

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Revenue Recognition

6 Months Ended

Jun. 30, 2022

Revenue from Contract with Customer [Abstract]

REVENUE RECOGNITION

REVENUE RECOGNITION

We generate revenues from services, products and intellectual property as follows:

Revenue from services

Revenue for laboratory services is recognized at the time test results are reported, which approximates when services are provided and the performance obligations are satisfied. Services are provided to patients covered by various third-party payor programs including various managed care organizations, as well as the Medicare and Medicaid programs. Billings for services are included in revenue net of allowances for contractual discounts, allowances for differences between the amounts billed and estimated program payment amounts, and implicit price concessions provided to uninsured patients which are all elements of variable consideration.

The following are descriptions of our payors for laboratory services:

Healthcare Insurers. Reimbursements from healthcare insurers are based on negotiated fee-for-service schedules. Revenues consist of amounts billed, net of contractual allowances for differences between amounts billed and the estimated consideration we expect to receive from such payors, which considers historical denial and collection experience and the terms of our contractual arrangements. Adjustments to the allowances, based on actual receipts from the third-party payors, are recorded upon settlement.

Government Payors. Reimbursements from government payors are based on fee-for-service schedules set by governmental authorities, including traditional Medicare and Medicaid. Revenues consist of amounts billed, net of contractual allowances for differences between amounts billed and the estimated consideration we expect to receive from such payors, which considers historical denial and collection experience and the terms of our contractual arrangements. Adjustments to the allowances, based on actual receipts from the government payors, are recorded upon settlement.

Client Payors. Client payors include physicians, hospitals, employers, and other institutions for which services are performed on a wholesale basis, and are billed and recognized as revenue based on negotiated fee schedules. Client payors also include cities, states and companies for which BioReference provides COVID-19 testing services.

Patients. Uninsured patients are billed based on established patient fee schedules or fees negotiated with physicians on behalf of their patients. Insured patients (including amounts for coinsurance and deductible responsibilities) are billed based on fees negotiated with healthcare insurers. Collection of billings from patients is subject to credit risk and ability of the patients to pay. Revenues consist of amounts billed net of discounts provided to uninsured patients in accordance with our policies and implicit price concessions. Implicit price concessions represent differences between amounts billed and the estimated consideration that we expect to receive from patients, which considers historical collection experience and other factors including current market conditions. Adjustments to the estimated allowances, based on actual receipts from the patients, are recorded upon settlement.

The complexities and ambiguities of billing, reimbursement regulations and claims processing, as well as considerations unique to Medicare and Medicaid programs, require us to estimate the potential for retroactive adjustments as an element of variable consideration in the recognition of revenue in the period the related services are rendered. Actual amounts are adjusted in the period those adjustments become known. For the six months ended June 30, 2022, negative revenue adjustments due to changes in estimates of implicit price concessions for performance obligations satisfied in prior periods of $21.2 million were recognized. Revenue adjustments for the six months ended June 30, 2022 were primarily due to lower COVID-19 test reimbursement estimates. For the six months ended June 30, 2021, positive revenue adjustments due to changes in estimates of implicit price concessions for performance obligations satisfied in prior periods of $28.5 million were recognized. Revenue adjustments for the six months ended June 30, 2021 were primarily due to an increase in COVID-19 test reimbursement estimates.

Third-party payors, including government programs, may decide to deny payment or recoup payments for testing they contend were improperly billed or not medically necessary, against their coverage determinations, or for which they believe they have otherwise overpaid (including as a result of their own error), and we may be required to refund payments already received. Our revenues may be subject to retroactive adjustment as a result of these factors among others, including without limitation, differing interpretations of billing and coding guidance and changes by government agencies and payors in interpretations, requirements, and “conditions of participation” in various programs. We have processed requests for recoupment from third-party payors in the ordinary course of our business, and it is likely that we will continue to do so in the future. If a third-party payor denies payment for testing or recoups money from us in a later period, reimbursement for our testing could decline.

As an integral part of our billing compliance program, we periodically assess our billing and coding practices, respond to payor audits on a routine basis, and investigate reported failures or suspected failures to comply with federal and state healthcare reimbursement requirements, as well as overpayment claims which may arise from time to time without fault on the part of the Company. We may have an obligation to reimburse Medicare, Medicaid, and third-party payors for overpayments regardless of fault. We have periodically identified and reported overpayments, reimbursed payors for overpayments and taken appropriate corrective action.

Settlements with third-party payors for retroactive adjustments due to audits, reviews or investigations are also considered variable consideration and are included in the determination of the estimated transaction price for providing services. These settlements are estimated based on the terms of the payment agreement with the payor, correspondence from the payor and our historical settlement activity, including an assessment of the probability a significant reversal of cumulative revenue recognized will occur when the uncertainty is subsequently resolved. Estimated settlements are adjusted in future periods as adjustments become known (that is, new information becomes available), or as years are settled or are no longer subject to such audits, reviews, and investigations. As of June 30, 2022 and December 31, 2021, we had liabilities of approximately $1.5 million and $5.0 million, respectively, within Accrued expenses and Other long-term liabilities related to reimbursements for payor overpayments.

The composition of revenue from services by payor for the three and six months ended June 30, 2022 and 2021 was as follows:

	Three months ended June 30,				Six months ended June 30,
(In thousands)	2022		2021		2022		2021
Healthcare insurers	$	76,442	$	109,084	$	172,269	$	273,913
Government payers	25,659		57,611		53,263		131,269
Client payers	80,931		225,936		240,021		488,845
Patients	3,772		4,566		7,849		10,122
Total	$	186,804	$	397,197	$	473,402	$	904,149

Revenue from products

We recognize revenue from product sales when a customer obtains control of promised goods or services. The amount of revenue that is recorded reflects the consideration that we expect to receive in exchange for those goods or services. Our estimates for sales returns and allowances are based upon the historical patterns of product returns and allowances taken, matched against the sales from which they originated, and our evaluation of specific factors that may increase or decrease the risk of product returns. Product revenues are recorded net of estimated rebates, chargebacks, discounts, co-pay assistance and other deductions (collectively, “Sales Deductions”) as well as estimated product returns which are all elements of variable consideration. Allowances are recorded as a reduction of revenue at the time product revenues are recognized. The actual amounts of consideration ultimately received may differ from our estimates. If actual results in the future vary from our estimates, we will adjust these estimates, which would affect Revenue from products in the period such variances become known.

Rayaldee is distributed in the U.S. principally through the retail pharmacy channel, which initiates with the largest wholesalers in the U.S. (collectively, “Rayaldee Customers”). In addition to distribution agreements with Rayaldee Customers, we have entered into arrangements with many healthcare providers and payors that provide for government-mandated and/or privately-negotiated rebates, chargebacks and discounts with respect to the purchase of Rayaldee.

We recognize revenue for shipments of Rayaldee at the time of delivery to customers after estimating Sales Deductions and product returns as elements of variable consideration utilizing historical information and market research projections. For the three and six months ended June 30, 2022, we recognized $6.2 million and $11.3 million, respectively, in net product revenue from sales of Rayaldee. For the three and six months ended June 30, 2021, we recognized $5.0 million and $10.8 million, respectively, in net product revenue from sales of Rayaldee.

The following table presents an analysis of product sales allowances and accruals for the three and six months ended June 30, 2022 and 2021:

(In thousands)	Chargebacks, discounts, rebates and fees		Governmental		Returns		Total
Balance at March 31, 2022	$	1,588	$	5,282	$	2,333	$	9,203
Provision related to current period sales	3,411		5,442		308		9,161
Credits or payments made	(3,330)		(4,235)		(1,023)		(8,588)
Balance at June 30, 2022	$	1,669	$	6,489	$	1,618	$	9,776
Total gross Rayaldee sales							$	15,382
Provision for Rayaldee sales allowances and accruals as a percentage of gross Rayaldee sales							60%

(In thousands)	Chargebacks, discounts, rebates and fees		Governmental		Returns		Total
Balance at December 31, 2021	$	2,014	$	5,499	$	2,639	$	10,152
Provision related to current period sales	6,626		10,311		577		17,514
Credits or payments made	(6,971)		(9,321)		(1,598)		(17,890)
Balance at June 30, 2022	$	1,669	$	6,489	$	1,618	$	9,776
Total gross Rayaldee sales							$	28,861
Provision for Rayaldee sales allowances and accruals as a percentage of gross Rayaldee sales							61%

(In thousands)	Chargebacks, discounts, rebates and fees		Governmental		Returns		Total
Balance at March 31, 2021	$	1,693	$	6,209	$	3,487	$	11,389
Provision related to current period sales	3,724		7,061		322		11,107
Credits or payments made	(3,716)		(5,684)		(485)		(9,885)
Balance at June 30, 2021	$	1,701	$	7,586	$	3,324	$	12,611
Total gross Rayaldee sales							$	16,122
Provision for Rayaldee sales allowances and accruals as a percentage of gross Rayaldee sales							69%

(In thousands)	Chargebacks, discounts, rebates and fees		Governmental		Returns		Total
Balance at December 31, 2020	$	2,332	$	5,812	$	3,593	$	11,737
Provision related to current period sales	7,539		12,755		635		20,929
Credits or payments made	(8,170)		(10,981)		(904)		(20,055)
Balance at June 30, 2021	$	1,701	$	7,586	$	3,324	$	12,611
Total gross Rayaldee sales							$	31,767
Provision for Rayaldee sales allowances and accruals as a percentage of gross Rayaldee sales							66%

Taxes collected from customers related to revenues from services and revenues from products are excluded from revenues.

Revenue from intellectual property and other

We recognize revenues from the transfer of intellectual property generated through license, development, collaboration and/or commercialization agreements. The terms of these agreements typically include payment to us for one or more of the following: non-refundable, up-front license fees; development and commercialization milestone payments; funding of research and/or development activities; and royalties on sales of licensed products. Revenue is recognized upon satisfaction of a performance obligation by transferring control of a good or service to the customer.

For research, development and/or commercialization agreements that result in revenues, we identify all material performance obligations, which may include a license to intellectual property and know-how, and research and development activities. In order to determine the transaction price, in addition to any upfront payment, we estimate the amount of variable consideration at the outset of the contract either utilizing the expected value or most likely amount method, depending on the facts and circumstances relative to the contract. We constrain (reduce) our estimates of variable consideration such that it is probable that a significant reversal of previously recognized revenue will not occur throughout the life of the contract. When determining if variable consideration should be constrained, we consider whether there are factors outside of our control that could result in a significant reversal of revenue. In making these assessments, we consider the likelihood and magnitude of a potential reversal of revenue. These estimates are re-assessed each reporting period as required.

Upfront License Fees: If a license to our intellectual property is determined to be functional intellectual property distinct from the other performance obligations identified in the arrangement, we recognize revenue from nonrefundable, upfront license fees based on the relative value prescribed to the license compared to the total value of the arrangement. The revenue is recognized when the license is transferred to the customer and the customer is able to use and benefit from the license. For licenses that are not distinct from other obligations identified in the arrangement, we utilize judgment to assess the nature of the combined performance obligation to determine whether the combined performance obligation is satisfied over time or at a point in time. If the combined performance obligation is satisfied over time, we apply an appropriate method of measuring progress for purposes of recognizing revenue from nonrefundable, upfront license fees. We evaluate the measure of progress each reporting period and, if necessary, adjust the measure of performance and related revenue recognition.

Development and Regulatory Milestone Payments: Depending on facts and circumstances, we may conclude that it is appropriate to include the milestone in the estimated transaction price or that it is appropriate to fully constrain the milestone. A milestone payment is included in the transaction price in the reporting period that we conclude that it is probable that recording revenue in the period will not result in a significant reversal in amounts recognized in future periods. We may record revenues from certain milestones in a reporting period before the milestone is achieved if we conclude that achievement of the milestone is probable and that recognition of revenue related to the milestone will not result in a significant reversal in amounts recognized in future periods. We record a corresponding contract asset when this conclusion is reached. Milestone payments that have been fully constrained are not included in the transaction price to date. These milestones remain fully constrained until we conclude that achievement of the milestone is probable and that recognition of revenue related to the milestone will not result in a significant reversal in amounts recognized in future periods. We re-evaluate the probability of achievement of such development milestones and any related constraint each reporting period. We adjust our estimate of the overall transaction price, including the amount of revenue recorded, if necessary.

Research and Development Activities: If we are entitled to reimbursement from our customers for specified research and development expenses, we account for them as separate performance obligations if distinct. We also determine whether the research and development funding would result in revenues or an offset to research and development expenses in accordance with provisions of gross or net revenue presentation. The corresponding revenues or offset to research and development expenses are recognized as the related performance obligations are satisfied.

Sales-based Milestone and Royalty Payments: Our customers may be required to pay us sales-based milestone payments or royalties on future sales of commercial products. We recognize revenues related to sales-based milestone and royalty payments upon the later to occur of (i) achievement of the customer’s underlying sales or (ii) satisfaction of any performance obligation(s) related to these sales, in each case assuming the license to our intellectual property is deemed to be the predominant item to which the sales-based milestones and/or royalties relate.

Other Potential Products and Services: Arrangements may include an option for license rights, future supply of drug substance or drug product for either clinical development or commercial supply at the licensee’s election. We assess if these options provide a material right to the licensee and if so, they are accounted for as separate performance obligations at the inception of the contract and revenue is recognized only if the option is exercised and products or services are subsequently delivered or when the rights expire. If the promise is based on market terms and not considered a material right, the option is accounted for if and when exercised. If we are entitled to additional payments when the licensee exercises these options, any additional payments are generally recorded in license or other revenues when the licensee obtains control of the goods, which is upon delivery.

For the three and six months ended June 30, 2022, revenue from transfer of intellectual property and other reflects $2.3 million and $4.5 million of revenue related to the Pfizer Transaction (as defined below) and a $85.0 million regulatory milestone payments from Pfizer due from the commencement of sales from NGENLA (Somatrogon) in Europe and Japan. For the six months ended June 30, 2022, revenue from transfer of intellectual property and other includes $3.0 million related to a sales milestone from VFMCRP (as defined below). For the three and six months ended June 30, 2021, revenue from transfer of intellectual property principally reflects $2.8 million and $5.6 million of revenue, respectively, related to the Pfizer Transaction and a $5.0 million non-refundable upfront payment we have received under the Nicoya Agreement (as defined below).

Contract liabilities relate to cash consideration that OPKO receives in advance of satisfying the related performance obligations. Changes in the contractual liabilities balance during the six months ended June 30, 2022 are as follows:

(In thousands)
Balance at December 31, 2021	$	466
Balance at June 30, 2022	449
Revenue recognized in the period from:
Amounts included in contracts liability at the beginning of the period	17

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Strategic Alliances

6 Months Ended

Jun. 30, 2022

Organization, Consolidation and Presentation of Financial Statements [Abstract]

STRATEGIC ALLIANCES

STRATEGIC ALLIANCES

LeaderMed

On September 14, 2021, we and LeaderMed Health Group Limited (“LeaderMed”), a pharmaceutical development company with operations based in Asia, announced the formation of a joint venture to develop, manufacture and commercialize two of OPKO’s clinical stage, long-acting drug products in Greater China and eight other Asian territories.

Under the terms of the agreements, we have granted the joint venture exclusive rights to develop, manufacture and commercialize (a) OPK88003, an oxyntomodulin analog being developed for the treatment of obesity and diabetes, and (b) Factor VIIa-CTP, a novel long-acting coagulation factor being developed to treat hemophilia, in exchange for a 47% ownership interest in the joint venture. In addition, we received an upfront payment of $1 million and will be reimbursed for clinical trial material and technical support we provide the joint venture. We recognized the upfront payment of $1 million as revenue from transfer of intellectual property and other during the year ended December 31, 2021.

LeaderMed has agreed to be responsible for funding the joint venture’s operations, development and commercialization efforts and, together with its syndicate partners, initially invested $11 million in exchange for a 53% ownership interest. We retain full rights to oxyntomodulin and Factor VIIa-CTP in all other geographies.

CAMP4 Therapeutics

On July 6, 2021, we entered into an exclusive license agreement (the “CAMP4 Agreement”) with CAMP4, pursuant to which we granted to CAMP4 an exclusive license to develop, manufacture, commercialize or improve therapeutics utilizing the AntagoNAT technology, an oligonucleotide platform developed under OPKO CURNA, which includes the molecule for the treatment of Dravet syndrome, together with any derivative or modification thereof (the “Licensed Compound”) and any pharmaceutical product that comprises or contains the Licensed Compound, alone or in combination with one or more other active ingredients (“Licensed Product”), worldwide. The CAMP4 Agreement grant covers human pharmaceutical, prophylactic, and therapeutic and certain diagnostic uses.

We received an initial upfront payment of $1.5 million and 3,373,008 shares of CAMP4’s Series A Prime Preferred Stock (“Preferred Stock”), which equates to approximately 9% of the outstanding shares of CAMP4, and we are eligible to receive up to $3.5 million in development milestone payments for Dravet syndrome products, and $4 million for non-Dravet syndrome products, as well as sales milestones of up to $90 million for Dravet syndrome products and up to $90 million for non-Dravet syndrome products. We may also receive double digit royalty payments on the net sales of royalty bearing products, subject to adjustment. In addition, upon achievement of certain development milestones, we will be eligible to receive equity consideration of up to 5,782,299 shares of Preferred Stock in connection with Dravet syndrome products and up to 1,082,248 shares of Preferred Stock in connection with non-Dravet syndrome products. In connection with our acquisition of CURNA, we agreed to pay future consideration to the sellers upon the achievement of certain events. As a result of our execution of the CAMP4 Agreement, we will have to pay a percentage of any payments received under the CAMP4 Agreement to the former CURNA stockholders.

Unless earlier terminated, the CAMP4 Agreement will remain in effect on a Licensed Product-by-Licensed Product and country by-country basis until such time as the royalty term expires for a Licensed Product in a country, and expires in its entirety upon the expiration of the royalty term for the last Licensed Product in the last country. CAMP4’s royalty obligations expire on the later of (i) the expiration, invalidation or abandonment date of the last patent right in connection with the royalty bearing product, or (ii) ten (10) years after a royalty bearing product’s first commercial sale in a country. In addition to termination rights for material breach and bankruptcy, CAMP4 is permitted to terminate the Agreement after a specified notice period.

NICOYA Macau Limited

On June 18, 2021, EirGen, our wholly owned subsidiary, and NICOYA Macau Limited (“Nicoya”), a Macau corporation and an affiliate of NICOYA Therapeutics, entered into a Development and License Agreement (the “Nicoya Agreement”) granting Nicoya the exclusive rights for the development and commercialization of extended release calcifediol (the “Nicoya Product”) in Greater China, which includes mainland China, Hong Kong, Macau, and Taiwan (collectively, the “Nicoya Territory”). Extended release calcifediol is marketed in the U.S. by OPKO under the tradename Rayaldee. The license grant to Nicoya covers the therapeutic and preventative use of the Nicoya Product for SHPT in non-dialysis and hemodialysis chronic kidney disease patients (the “Nicoya Field”).

EirGen has received an initial upfront payment of $5 million and is eligible to receive an additional $5 million upon the first to occur of (A) a predetermined milestone and (B) the first anniversary of the effective date. EirGen is also eligible to receive up to an additional aggregate amount of $115 million upon the achievement of certain development, regulatory and sales-based milestones by Nicoya for the Nicoya Product in the Nicoya Territory. EirGen will also receive tiered, double digit royalty payments at rates in the low double digits on net product sales within the Nicoya Territory and in the Nicoya Field.

Nicoya will, at its sole cost and expense, be responsible for performing all development activities necessary to obtain all regulatory approvals for the Nicoya Product in the Nicoya Territory and for all commercial activities pertaining to the Nicoya Product in the Nicoya Territory.

Unless earlier terminated, the Nicoya Agreement will remain in effect until such time as all royalty payment terms and extended payment terms have expired, and Nicoya shall have no further payment obligations to EirGen under the terms of the Nicoya Agreement. Nicoya’s royalty obligations expire on the later of (i) expiration of the last to expire valid patent claim covering the Nicoya Product sold in the Nicoya Territory, (ii) expiration of all regulatory and data exclusivity applicable to the Nicoya Product in the Nicoya Territory, and (iii) on a product-by-product basis, ten (10) years after such Nicoya Product’s first commercial sale in the Nicoya Territory. In addition to termination rights for material breach and bankruptcy, Nicoya is permitted to terminate the Nicoya Agreement after a specified notice period.

Vifor Fresenius Medical Care Renal Pharma Ltd

In May 2016, EirGen and Vifor Fresenius Medical Care Renal Pharma Ltd. (“VFMCRP”) entered into a Development and License Agreement (the “VFMCRP Agreement”) for the development and commercialization of Rayaldee (the “Product”) worldwide, except for (i) the U.S., (ii) any country in Central America or South America (including Mexico), (iii) Russia, (iv) China, (v) South Korea, (vi) Ukraine, (vii) Belorussia, (viii) Azerbaijan, (ix) Kazakhstan, (x) Taiwan (xi) the Middle East, and (xii) all countries of Africa (the “VFMCRP Territory”), as amended. The license to VFMCRP potentially covers all therapeutic and prophylactic uses of the Product in human patients (the “VFMCRP Field”), provided that initially the license is for the use of the Product for the treatment or prevention of SHPT related to patients with CKD and vitamin D insufficiency/deficiency (the “VFMCRP Initial Indication”).

For the six months ended June 30, 2022 we recognized a milestone payment of $3.0 million in revenue from transfer of intellectual property and other for the first sale of Rayaldee in Europe.

Effective May 23, 2021, we entered into an amendment to the VFMCRP Agreement pursuant to which the parties thereto agreed to include Japan as part of the VFMCRP Territory.

Effective May 5, 2020, we entered into an amendment to the VFMCRP Agreement pursuant to which the parties agreed to exclude Mexico, South Korea, the Middle East and all of the countries of Africa from the VFMCRP Territory. In addition, the parties agreed to certain amendments to the milestone structure and to reduce minimum royalties payable. As revised, the Company has received a $3 million payment triggered by the first marketing approval of Rayaldee in Europe and is eligible to receive up to an additional $17 million in regulatory milestones and $207 million in milestone payments tied to launch, pricing and sales of Rayaldee, and tiered, double-digit royalties.

We plan to share responsibility with VFMCRP for the conduct of trials specified within an agreed-upon development plan, with each company leading certain activities within the plan. EirGen will lead the manufacturing activities within and outside the VFMCRP Territory and the commercialization activities outside the VFMCRP Territory and outside the VFMCRP Field in the VFMCRP Territory and VFMCRP will lead the commercialization activities in the VFMCRP Territory and the VFMCRP Field. For the initial development plan, the companies have agreed to certain cost sharing arrangements. VFMCRP will be responsible for all other development costs that VFMCRP considers necessary to develop the Product for the use of the Product for the VFMCRP Initial Indication in the VFMCRP Territory in the VFMCRP Field except as otherwise provided in the VFMCRP Agreement. The first of the clinical studies provided for in the development activities commenced in September 2018.

In connection with the VFMCRP Agreement, the parties entered into a letter agreement pursuant to which EirGen granted to VFMCRP an exclusive option (the “Option”) to acquire an exclusive license under certain EirGen patents and technology to use, import, offer for sale, sell, distribute and commercialize the Product in the U.S. solely for the treatment of SHPT in dialysis patients with CKD and vitamin D insufficiency (the “Dialysis Indication”). Upon exercise of the Option, VFMCRP will reimburse EirGen for all of the development costs incurred by EirGen with respect to the Product for the Dialysis Indication in the U.S. VFMCRP would also pay EirGen up to an additional aggregate amount of $555 million of sales-based milestones upon the achievement of certain milestones and would be obligated to pay royalties at percentage rates that range from the mid-teens to the mid-twenties on sales of the Product in the U.S. for the Dialysis Indication. To date, VFMCRP has not exercised its option.

Payments received for regulatory milestones and sales milestones are non-refundable. The regulatory milestones are payable if and when VFMCRP obtains approval from certain regulatory authorities and will be recognized as revenue in the period in which the associated milestone is achieved, assuming all other revenue recognition criteria are met. We account for the sales milestones as royalties and sales milestones payments will be recognized as revenue in the period in which the associated milestone is achieved or sales occur, assuming all other revenue recognition criteria are met.

Pfizer Inc.

In December 2014, we entered into an exclusive worldwide agreement (the “Pfizer Agreement”) with Pfizer for the development and commercialization of our long-acting Somatrogon (hGH-CTP) for the treatment of growth hormone deficiency (“GHD”) in adults and children, as well as for the treatment of growth failure in children born small for gestational age (the “Pfizer Transaction”).

In early 2022, the European Commission and Ministry of Health, Labour and Welfare in Japan approved the next-generation long-acting recombinant human growth hormone NGENLA (Somatrogon), a once-weekly injection to treat pediatric growth hormone deficiency, and we received pricing approvals in Germany and Japan. With the achievement of these milestones, we received $85.0 million in milestone payments during the second quarter of 2022. Further, Canada and Australia approved NGENLA in October and November of 2021, respectively.

In January 2022, the FDA issued a Complete Response Letter for the BLA for Somatrogon (hGH-CTP). Pfizer and OPKO are evaluating the FDA’s comments and will work with the agency to determine the best path forward for Somatrogon (hGH-CTP) in the United States.

In May 2020, we entered into an Amended and Restated Development and Commercialization License Agreement (the “Restated Pfizer Agreement”) with Pfizer, effective January 1, 2020, pursuant to which the parties agreed, among other things, to share all costs for Manufacturing Activities, as defined in the Restated Pfizer Agreement, for developing a licensed product for the three indications included in the Restated Pfizer Agreement.

On October 21, 2019, we and Pfizer announced that the global phase 3 trial evaluating Somatrogon dosed once-weekly in prepubertal children with GHD met its primary endpoint of non-inferiority to daily Genotropin® (somatropin) for injection, as measured by annual height velocity at 12 months.

Under the terms of the Pfizer Transaction, as restated, we received non-refundable and non-creditable upfront payments of $295.0 million and are eligible to receive up to an additional $275.0 million upon the achievement of certain regulatory milestones. Pfizer received the exclusive license to commercialize Somatrogon worldwide. In addition, we are eligible to receive initial tiered royalty payments associated with the commercialization of Somatrogon for adult GHD with percentage rates ranging from the high teens to mid-twenties. Upon the launch of Somatrogon for pediatric GHD in certain major markets, the royalties will transition to regional, tiered gross profit sharing for both Somatrogon and Pfizer’s Genotropin®.

The agreement with Pfizer will remain in effect until the last sale of the licensed product, unless earlier terminated as permitted under the Pfizer Agreement. In addition to termination rights for material breach and bankruptcy, Pfizer is permitted

to terminate the Pfizer Agreement in its entirety, or with respect to one or more world regions, without cause after a specified notice period. If the Pfizer Agreement is terminated by us for Pfizer’s uncured material breach, or by Pfizer without cause, provision has been made for transition of product and product responsibilities to us for the terminated regions, as well as continued supply of product by Pfizer or transfer of supply to us in order to support the terminated regions.

We recognized the non-refundable $295.0 million upfront payments as revenue as the research and development services were completed and as of both June 30, 2022 and December 31, 2021, we had no contract liabilities related to the Pfizer Transaction.

The Pfizer Transaction includes milestone payments of $275.0 million upon the achievement of certain milestones. The milestones range from $20.0 million to $90.0 million each and are based on achievement of regulatory approval in the U.S. and regulatory approval and price approval in other major markets. The milestone payments will be recognized as revenue in the period in which the associated milestone is achieved, assuming all other revenue recognition criteria are met. To date, $85.0 million of revenue has been recognized related to the achievement of the milestones.

Other

We have completed strategic deals with numerous institutions and commercial partners. In connection with these agreements, upon the achievement of certain milestones we are obligated to make certain payments and have royalty obligations upon sales of products developed under the license agreements. At this time, we are unable to estimate the timing and amounts of payments as the obligations are based on future development of the licensed products.

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Segments

6 Months Ended

Jun. 30, 2022

Segment Reporting [Abstract]

SEGMENTS

SEGMENTS

We manage our operations in two reportable segments, pharmaceutical and diagnostics. The pharmaceutical segment consists of our pharmaceutical operations in Chile, Mexico, Ireland, Israel and Spain, Rayaldee product sales and our pharmaceutical research and development. The diagnostics segment primarily consists of our clinical and genomics laboratory operations through BioReference and our point-of-care operations. There are no significant inter-segment sales. We evaluate the performance of each segment based on operating profit or loss. There is no inter-segment allocation of interest expense and income taxes.

Information regarding our operations and assets for our operating segments and the unallocated corporate operations as well as geographic information are as follows:

	For the three months ended June 30,				For the six months ended June 30,
(In thousands)	2022		2021		2022		2021
Revenue from services:
Pharmaceutical	$	—	$	—	$	—	$	—
Diagnostics	186,804		397,197		473,402		904,149
Corporate	—		—		—		—
	$	186,804	$	397,197	$	473,402	$	904,149
Revenue from products:
Pharmaceutical	$	35,892	$	35,663	$	72,550	$	69,608
Diagnostics	—		—		—		—
Corporate	—		—		—		—
	$	35,892	$	35,663	$	72,550	$	69,608
Revenue from transfer of intellectual property and other:
Pharmaceutical	$	87,197	$	9,548	$	93,159	$	13,816
Diagnostics	—		—		—		—
Corporate	—		—		—		—
	$	87,197	$	9,548	$	93,159	$	13,816
Operating income (loss):
Pharmaceutical	$	55,435	$	(13,710)	$	37,327	$	(32,868)
Diagnostics	(57,543)		30,000		(101,092)		97,014
Corporate	(8,631)		(10,719)		(19,399)		(20,138)
	$	(10,739)	$	5,571	$	(83,164)	$	44,008
Depreciation and amortization:
Pharmaceutical	$	17,840	$	7,007	$	33,242	$	14,420
Diagnostics	10,155		13,566		22,567		26,141
Corporate	—		—		—		—
	$	27,995	$	20,573	$	55,809	$	40,561
Loss from investment in investees:
Pharmaceutical	$	(268)	$	(67)	$	(316)	$	(110)
Diagnostics	—		—		—		—
Corporate	—		—		—		—
	$	(268)	$	(67)	$	(316)	$	(110)
Revenues:
United States	$	193,105	$	402,291	$	484,913	$	915,163
Ireland	89,177		12,088		97,638		19,218
Chile	15,804		18,657		32,143		32,809
Spain	5,696		5,437		12,805		11,356
Israel	1,854		724		3,412		3,235
Mexico	4,055		3,039		7,805		5,457
Other	202		172		395		335
	$	309,893	$	442,408	$	639,111	$	987,573

(In thousands)	June 30, 2022		December 31, 2021
Assets:
Pharmaceutical	$	1,354,058	$	1,114,460
Diagnostics	748,165		1,238,583
Corporate	267,379		46,672
	$	2,369,602	$	2,399,715
Goodwill:
Pharmaceutical	$	295,820	$	237,576
Diagnostics	283,025		283,025
	$	578,845	$	520,601

No customer represented more than 10% of our total consolidated revenue during the six months ended June 30, 2022 and 2021. As of June 30, 2022 and December 31, 2021, no customer represented more than 10% of our accounts receivable balance.

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Leases

6 Months Ended

Jun. 30, 2022

Leases [Abstract]

LEASES

LEASES

We have operating leases for office space, laboratory operations, research and development facilities, manufacturing locations, warehouses and certain equipment. We determine if a contract contains a lease at inception or modification of a contract. Our leases generally do not provide an implicit interest rate, and we therefore use our incremental borrowing rate as the discount rate when measuring operating lease liabilities. The incremental borrowing rate represents an estimate of the interest rate we would incur at lease commencement to borrow an amount equal to the lease payments on a collateralized basis over the term of the lease within a particular currency environment. We used the incremental borrowing rates as of January 1, 2019 for operating leases that commenced prior to that date. Many of our leases contain rental escalation, renewal options and/or termination options that are factored into our determination of lease payments as appropriate. Variable lease payment amounts that cannot be determined at the commencement of the lease are not included in the right-to-use assets or liabilities.

We elected the use of permitted practical expedients of not recording leases on our Consolidated Balance Sheet when the leases have terms of 12 months or less, and we elected not to separate nonlease components from lease components and instead account for each separate lease component and the nonlease components associated with that lease component as a single lease component.

The following table presents the lease balances within the Condensed Consolidated Balance Sheet as of June 30, 2022 and December 31, 2021:

(in thousands)	Classification on the Balance Sheet	June 30, 2022			December 31, 2021
Assets
Operating lease assets	Operating lease right-of-use assets	$	42,412		$	44,228
Finance lease assets	Property, plant and equipment, net	7,213			5,181
Liabilities
Current
Operating lease liabilities	Current maturities of operating leases	12,122			11,624
Accrued expenses	Current maturities of finance leases	2,625			2,257
Long-term
Operating lease liabilities	Operating lease liabilities	30,876			33,097
Other long-term liabilities	Finance lease liabilities	$	4,588		$	2,924
Weighted average remaining lease term
Operating leases		6.4 years			7.2 years
Finance leases		3.2 years			2.4 years
Weighted average discount rate
Operating leases		3.7		%	4.6		%
Finance leases		7.0		%	4.8		%

The following table reconciles the undiscounted future minimum lease payments (displayed by year and in the aggregate) under noncancelable operating leases with terms of more than one year to the total operating lease liabilities recognized on our Condensed Consolidated Balance Sheet as of June 30, 2022:

(in thousands)	Operating		Finance
July 1, 2022 through December 31, 2022	$	6,322	$	1,528
2023	10,399		2,430
2024	7,025		1,829
2025	4,541		1,291
2026	3,654		636
Thereafter	15,493		2
Total undiscounted future minimum lease payments	47,434		7,716
Less: Difference between lease payments and discounted lease liabilities	4,436		503
Total lease liabilities	$	42,998	$	7,213

Expense under operating leases and finance leases was $8.4 million and $1.9 million, respectively, for the six months ended June 30, 2022, which includes $1.3 million of variable lease costs. Expense under operating leases and finance leases was $9.1 million and $1.1 million, respectively, for the six months ended June 30, 2021, which includes $1.4 million of variable lease costs. Operating lease costs and finance lease costs are included within Operating loss in the Condensed Consolidated Statement of Operations. Short-term lease costs were not material.

Supplemental cash flow information is as follows:

(in thousands)	For the six months ended June 30,
	2022		2021
Operating cash out flows from operating leases	$	8,327	$	6,484
Operating cash out flows from finance leases	52		45
Financing cash out flows from finance leases	724		769
Total	$	9,103	$	7,298

LEASES

LEASES

We have operating leases for office space, laboratory operations, research and development facilities, manufacturing locations, warehouses and certain equipment. We determine if a contract contains a lease at inception or modification of a contract. Our leases generally do not provide an implicit interest rate, and we therefore use our incremental borrowing rate as the discount rate when measuring operating lease liabilities. The incremental borrowing rate represents an estimate of the interest rate we would incur at lease commencement to borrow an amount equal to the lease payments on a collateralized basis over the term of the lease within a particular currency environment. We used the incremental borrowing rates as of January 1, 2019 for operating leases that commenced prior to that date. Many of our leases contain rental escalation, renewal options and/or termination options that are factored into our determination of lease payments as appropriate. Variable lease payment amounts that cannot be determined at the commencement of the lease are not included in the right-to-use assets or liabilities.

We elected the use of permitted practical expedients of not recording leases on our Consolidated Balance Sheet when the leases have terms of 12 months or less, and we elected not to separate nonlease components from lease components and instead account for each separate lease component and the nonlease components associated with that lease component as a single lease component.

The following table presents the lease balances within the Condensed Consolidated Balance Sheet as of June 30, 2022 and December 31, 2021:

(in thousands)	Classification on the Balance Sheet	June 30, 2022			December 31, 2021
Assets
Operating lease assets	Operating lease right-of-use assets	$	42,412		$	44,228
Finance lease assets	Property, plant and equipment, net	7,213			5,181
Liabilities
Current
Operating lease liabilities	Current maturities of operating leases	12,122			11,624
Accrued expenses	Current maturities of finance leases	2,625			2,257
Long-term
Operating lease liabilities	Operating lease liabilities	30,876			33,097
Other long-term liabilities	Finance lease liabilities	$	4,588		$	2,924
Weighted average remaining lease term
Operating leases		6.4 years			7.2 years
Finance leases		3.2 years			2.4 years
Weighted average discount rate
Operating leases		3.7		%	4.6		%
Finance leases		7.0		%	4.8		%

The following table reconciles the undiscounted future minimum lease payments (displayed by year and in the aggregate) under noncancelable operating leases with terms of more than one year to the total operating lease liabilities recognized on our Condensed Consolidated Balance Sheet as of June 30, 2022:

(in thousands)	Operating		Finance
July 1, 2022 through December 31, 2022	$	6,322	$	1,528
2023	10,399		2,430
2024	7,025		1,829
2025	4,541		1,291
2026	3,654		636
Thereafter	15,493		2
Total undiscounted future minimum lease payments	47,434		7,716
Less: Difference between lease payments and discounted lease liabilities	4,436		503
Total lease liabilities	$	42,998	$	7,213

Expense under operating leases and finance leases was $8.4 million and $1.9 million, respectively, for the six months ended June 30, 2022, which includes $1.3 million of variable lease costs. Expense under operating leases and finance leases was $9.1 million and $1.1 million, respectively, for the six months ended June 30, 2021, which includes $1.4 million of variable lease costs. Operating lease costs and finance lease costs are included within Operating loss in the Condensed Consolidated Statement of Operations. Short-term lease costs were not material.

Supplemental cash flow information is as follows:

(in thousands)	For the six months ended June 30,
	2022		2021
Operating cash out flows from operating leases	$	8,327	$	6,484
Operating cash out flows from finance leases	52		45
Financing cash out flows from finance leases	724		769
Total	$	9,103	$	7,298

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Subsequent Events

6 Months Ended

Jun. 30, 2022

Subsequent Events [Abstract]

SUBSEQUENT EVENTS

SUBSEQUENT EVENTS

The Company and BioReference entered into (i) a settlement agreement (the “Settlement Agreement”), effective July 14, 2022, with the United States of America, acting through the United States Department of Justice and on behalf of the Office of Inspector General of the Department of Health and Human Services (“OIG-HHS”), and the Defense Health Agency, acting on behalf of the TRICARE Program (collectively, the “United States”), the Commonwealth of Massachusetts (the “Commonwealth”), the State of Connecticut, (“Connecticut”), and the relator identified therein (“Relator”), and (ii) a Corporate Integrity Agreement, effective July 14, 2022 (the “CIA”), with the OIG-HHS, to resolve the investigation and related civil action concerning alleged fee-for-service claims for payment to the Medicare Program, the Medicaid Program, and the TRICARE Program (collectively, the “Federal Health Care Programs”).

Under the Settlement Agreement, the Company and BioReference admitted only to having made payments to certain physicians and physicians’ groups for office space rentals for amounts that exceeded fair market value, and that it did not report or return any such overpayments to the Federal Health Care Programs (the “Covered Conduct”). The Covered Conduct had commenced prior to the Company’s acquisition of BioReference in 2015. With the exception of the Covered Conduct, the Company and BioReference expressly deny the allegations of the Relator as set forth in her civil action. The Company has agreed to pay a total of $10,000,000 plus accrued interest from September 24, 2021 at a rate of 1.5% per annum (the “Settlement Amount”). The Settlement Amount consists of $9,853,958 payable to the United States, $141,041 payable to the Commonwealth and $5,001 payable to Connecticut, in each case plus interest and paid on July 18th, 2022. Conditioned upon payment of the Settlement Amount, the United States, the Commonwealth and Connecticut have agreed to release the Company and BioReference from any civil or administrative monetarily liability arising from the Covered Conduct. Upon payment of the Settlement Amount and the amount due under a separate agreement with the Relator, the Relator has agreed to release the Company and BioReference from any and all claims and potential claims. Further, in consideration of the obligations of the Company and BioReference in the Settlement Agreement and the CIA, the OIG-HHS has agreed to release and refrain from instituting any administrative action seeking to exclude the Company or BioReference from participating in Medicare, Medicaid or other Federal health care programs as a result of the Covered Conduct.

Under the CIA, which has a term of 5 years, BioReference is required to, among other things: (i) maintain a Compliance Officer, a Compliance Committee, board review and oversight of certain federal healthcare compliance matters, compliance programs, and disclosure programs; (ii) provide management certifications and compliance training and education; (iii) establish written compliance policies and procedures to meet federal health care program requirements; (iv) create procedures designed to ensure compliance with the Anti-Kickback Statute and/or Stark Law; (v) engage an independent review organization to conduct a thorough review of BioReference’ s systems, policies, processes and procedures related to certain arrangements; (vi) implement a risk assessment and internal review process; (vii) establish a disclosure program for whistleblowers; and (viii) report or disclose certain events and physician payments. The Company’s or BioReference’s failure to comply with its obligations under the CIA could result in monetary penalties and the exclusion from participation in Federal Health Care Programs. The CIA does not apply to any of the Company’s subsidiaries other than BioReference, and its scope is generally limited to “focus arrangements”, which are those “arrangements” (as defined in the CIA) (i) between BioReference and any actual source or recipient of health care business or referrals and involves, directly or indirectly, the offer, payment, or provision of anything of value, or (ii) is between BioReference and any physician (or a physician’s immediate family member). Most of these measures have already been implemented at BioReference. Following its acquisition of BioReference, the Company and BioReference implemented robust compliance measures that substantially align with those actions required under the CIA.

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Summary of Significant Accounting Policies (Policies)

6 Months Ended

Jun. 30, 2022

Accounting Policies [Abstract]

Basis of presentation

Basis of presentation. The accompanying unaudited Condensed Consolidated Financial Statements have been prepared in accordance with accounting principles generally accepted in the U.S. (“GAAP”) and with the instructions to Form 10-Q and Article 10 of Regulation S-X. Accordingly, they do not include all information and notes required by GAAP for complete financial statements. In the opinion of management, all adjustments (consisting of only normal recurring adjustments or adjustments otherwise disclosed herein) considered necessary to present fairly the Company’s results of operations, financial position and cash flows have been made. The results of operations and cash flows for the six months ended June 30, 2022 are not necessarily indicative of the results of operations and cash flows that may be reported for the remainder of 2022 or any other future periods. The unaudited Condensed Consolidated Financial Statements should be read in conjunction with the audited Consolidated Financial Statements and the Notes to Consolidated Financial Statements included in our Annual Report on Form 10-K for the year ended December 31, 2021.

Principles of consolidation

Principles of consolidation. The accompanying unaudited Condensed Consolidated Financial Statements include the accounts of OPKO Health, Inc. and our wholly-owned subsidiaries. All intercompany accounts and transactions are eliminated in consolidation.

Use of estimates

Use of estimates. The preparation of financial statements in conformity with GAAP requires management to make estimates and assumptions that affect the reported amounts of assets and liabilities and disclosure of contingent assets and liabilities at the date of the financial statements and the reported amounts of revenues and expenses during the reporting period. Actual results could differ significantly from these estimates.

Cash and cash equivalents

Cash and cash equivalents. Cash and cash equivalents include short-term, interest-bearing instruments with original maturities of 90 days or less at the date of purchase. We also consider all highly liquid investments with original maturities at the date of purchase of 90 days or less as cash equivalents. These investments include money markets, bank deposits, certificates of deposit and U.S. treasury securities.

Inventories

Inventories. Inventories are valued at the lower of cost and net realizable value. Cost is determined by the first-in, first-out method. We consider such factors as the amount of inventory on hand, estimated time required to sell such inventories, remaining shelf-life, and current market conditions to determine whether inventories are stated at the lower of cost and net realizable value. Inventories at our diagnostics segment consist primarily of purchased laboratory supplies, which are used in our testing laboratories.

Goodwill and intangible assets

Goodwill and intangible assets. Goodwill represents the difference between the purchase price and the estimated fair value of the net assets acquired accounted for by the acquisition method of accounting. Refer to Note 5. Goodwill, in-process research and development (“IPR&D”) and other intangible assets acquired in business combinations, licensing and other transactions was $1.6 billion and $1.4 billion, respectively, at June 30, 2022 and December 31, 2021.

Assets acquired and liabilities assumed in business combinations, licensing and other transactions are generally recognized at the date of acquisition at their respective fair values. Any excess of the purchase price over the estimated fair values of the net assets acquired is recognized as goodwill. At acquisition, we generally determine the fair value of intangible assets, including IPR&D, using the “income method.”

Subsequent to their acquisition, goodwill and indefinite lived intangible assets are tested at least annually as of October 1 for impairment, or when events or changes in circumstances indicate it is more likely than not that the carrying amount of such assets may not be recoverable.

Estimating the fair value of a reporting unit for goodwill impairment is highly sensitive to changes in projections and assumptions and changes in assumptions could potentially lead to impairment. We perform sensitivity analyses around our assumptions in order to assess the reasonableness of the assumptions and the results of our testing. Ultimately, potential changes in these assumptions may impact the estimated fair value of a reporting unit and result in an impairment if the fair value of such reporting unit is less than its carrying value. Goodwill was $578.8 million and $520.6 million, respectively, at June 30, 2022 and December 31, 2021. At December 31, 2021, Assets held for sale include $151.8 million of goodwill related to GeneDx.

Net intangible assets other than goodwill was $1,057.4 million and $911.9 million, including IPR&D of $195.0 million and $590.2 million at June 30, 2022 and December 31, 2021, respectively. Intangible assets are highly vulnerable to impairment charges, particularly newly acquired assets for recently launched products and IPR&D. Considering the high risk nature of research and development and the industry’s success rate of bringing developmental compounds to market, IPR&D impairment charges may occur in future periods. Estimating the fair value of IPR&D for potential impairment is highly sensitive to changes in projections and assumptions and changes in assumptions could potentially lead to impairment.

Upon obtaining regulatory approval, IPR&D assets are then accounted for as a finite-lived intangible asset and amortized on a straight-line basis over its estimated useful life. If the project is abandoned, the IPR&D asset is charged to expense. Finite lived intangible assets are tested for impairment when events or changes in circumstances indicate it is more likely than not that the carrying amount of such assets may not be recoverable. The testing includes a comparison of the carrying amount of the asset to its estimated undiscounted future cash flows expected to be generated by the asset. If the carrying amount of an asset exceeds its estimated undiscounted future cash flows, then an impairment charge is recognized for the amount by which the carrying amount of the asset exceeds the fair value of the asset.

We believe that our estimates and assumptions in testing goodwill and other intangible assets, including IPR&D, for

impairment are reasonable and otherwise consistent with assumptions that marketplace participants would use in their estimates

of fair value. However, if future results are not consistent with our estimates and assumptions, including as a result of the

COVID-19 global pandemic, then we may be exposed to additional impairment charges, which could be material. Pfizer submitted the initial BLA with the FDA for approval of Somatrogon (hGH-CTP) in the United States and Pfizer received a Complete Response Letter in January 2022. Pfizer and OPKO are evaluating the FDA’s comments and will work with the agency to determine the best path forward for Somatrogon (hGH-CTP) in the United States.

In the first quarter of 2022, we reclassified $590.0 million of IPR&D related to Somatrogon (hGH-CTP) from IPR&D in our Condensed Consolidated Balance Sheet upon the approval of NGENLA (Somatrogon) in Europe and Japan. The assets will be amortized on a straight-line basis over their estimated useful life of approximately 12 years.

We amortize intangible assets with definite lives on a straight-line basis over their estimated useful lives, ranging from 3 to 20 years. We use the straight-line method of amortization as there is no reliably determinable pattern in which the economic benefits of our intangible assets are consumed or otherwise used up.

Fair value measurements

Fair value measurements. The carrying amounts of our cash and cash equivalents, accounts receivable, accounts payable and short-term debt approximate their fair value due to the short-term maturities of these instruments. Investments that are considered equity securities as of June 30, 2022 and December 31, 2021 are predominately carried at fair value. Our debt under the Credit Agreement (as defined below) approximates fair value due to the variable rate of interest applicable to such debt.

In evaluating the fair value information, considerable judgment is required to interpret the market data used to develop the estimates. The use of different market assumptions and/or different valuation techniques may have a material effect on the

estimated fair value amounts. Accordingly, the estimates of fair value presented herein may not be indicative of the amounts that could be realized in a current market exchange.

Contingent consideration

Contingent consideration. Each period we revalue the contingent consideration obligations associated with certain prior acquisitions to their fair value and record increases in the fair value as contingent consideration expense and decreases in the fair value as a reduction in contingent consideration expense. Changes in contingent consideration result from changes in the assumptions regarding probabilities of successful achievement of related milestones, the estimated timing in which the milestones are achieved and the discount rate used to estimate the fair value of the liability. Contingent consideration may change significantly as our development programs progress, revenue estimates evolve and additional data is obtained, impacting our assumptions. The assumptions used in estimating fair value require significant judgment. The use of different assumptions and judgments could result in a materially different estimate of fair value which may have a material impact on our results from operations and financial position.

Derivative financial instruments

Derivative financial instruments. We record derivative financial instruments on our Condensed Consolidated Balance Sheet at their fair value and recognize the changes in the fair value in our Condensed Consolidated Statement of Operations when they occur, the only exception being derivatives that qualify as hedges. For the derivative instrument to qualify as a hedge, we are required to meet strict hedge effectiveness and contemporaneous documentation requirements at the initiation of the hedge and assess the hedge effectiveness on an ongoing basis over the life of the hedge. At June 30, 2022 and December 31, 2021, our foreign currency forward contracts held to economically hedge inventory purchases did not meet the documentation requirements to be designated as hedges. Accordingly, we recognized all changes in the fair values of our derivatives instruments, net, in our Condensed Consolidated Statement of Operations.

Property, plant and equipment

Property, plant and equipment. Property, plant and equipment are recorded at cost or fair value if acquired in a business combination. Depreciation is provided using the straight-line method over the estimated useful lives of the assets and includes amortization expense for assets capitalized under finance leases. The estimated useful lives by asset class are as follows: software - 3 years, machinery, medical and other equipment - 5-8 years, furniture and fixtures - 5-12 years, leasehold improvements - the lesser of their useful life or the lease term, buildings and improvements - 10-40 years, and automobiles - 3-5 years. Expenditures for repairs and maintenance are charged to expense as incurred. Assets held under finance leases are included within Property, plant and equipment, net in our Consolidated Balance Sheets and are amortized over the shorter of their useful lives or the expected term of their related leases.

Impairment of long-lived assets

Impairment of long-lived assets. Long-lived assets, such as property and equipment and assets held for sale, are reviewed for impairment whenever events or changes in circumstances indicate that the carrying amount of an asset may not be recoverable. Recoverability of assets to be held and used is measured by a comparison of the carrying amount of an asset to estimated undiscounted future cash flows expected to be generated by the asset. If the carrying amount of an asset exceeds its estimated future cash flows, then an impairment charge is recognized for the amount by which the carrying amount of the asset exceeds the fair value of the asset.

Income taxes

Income taxes. Income taxes are accounted for under the asset-and-liability method. Deferred tax assets and liabilities are recognized for the future tax consequences attributable to differences between the financial statement carrying amounts of existing assets and liabilities and the respective tax bases and for operating loss and tax credit carryforwards. Deferred tax assets and liabilities are measured using enacted tax rates expected to apply to taxable income in the years in which those temporary differences are expected to be recovered or settled. The effect on deferred tax assets and liabilities of a change in tax rates is recognized in operations in the period that includes the enactment date. We periodically evaluate the realizability of our net deferred tax assets. Our tax accruals are analyzed periodically and adjustments are made as events occur to warrant such adjustment. Valuation allowances on certain U.S. deferred tax assets and non-U.S. deferred tax assets are established, because realization of these tax benefits through future taxable income does not meet the more-likely-than-not threshold.

We operate in various countries and tax jurisdictions globally.  For interim reporting purposes, we record income taxes based on the expected effective income tax rate, taking into consideration year to date and global forecasted tax results.  For the six months ended June 30, 2022, the tax rate differed from the U.S. federal statutory rate of 21% primarily due to the valuation allowance against certain U.S. and non-U.S. deferred tax assets, the relative mix in earnings and losses in the U.S. versus foreign tax jurisdictions, and the impact of certain discrete tax events and operating results in tax jurisdictions which do not result in a tax benefit.

Revenue recognition and shipping and handling costs

Revenue recognition. We recognize revenue when a customer obtains control of promised goods or services in accordance with Accounting Standards Codification Topic 606, Revenue from Contracts with Customers (“Topic 606”). The amount of revenue that is recorded reflects the consideration that we expect to receive in exchange for those goods or services. We apply the following five-step model in order to determine this amount: (i) identify the contract(s) with a customer; (ii) identify the performance obligations in the contract; (iii) determine the transaction price; (iv) allocate the transaction price to the performance obligations in the contract; and (v) recognize revenue when (or as) we satisfy a performance obligation. We apply the five-step model to contracts when it is probable that we will collect the consideration we are entitled to in exchange for the goods or services we transfer to the customer. At contract inception, once the contract is determined to be within the scope of Topic 606, we review the contract to determine which performance obligations we must deliver and which of these performance obligations are distinct. We recognize as revenue the amount of the transaction price that is allocated to the respective performance obligation when the performance obligation is satisfied or as it is satisfied.Shipping and handling costs. We do not charge customers for shipping and handling costs. Shipping and handling costs are classified as Cost of revenues in the Condensed Consolidated Statement of Operations.

Concentration of credit risk and allowance for credit losses

Concentration of credit risk and allowance for credit losses. Financial instruments that potentially subject us to concentrations of credit risk consist primarily of accounts receivable. Substantially all of our accounts receivable are with either companies in the healthcare industry or patients. However, credit risk is limited due to the number of our clients as well as their dispersion across many different geographic regions.While we have receivables due from federal and state governmental agencies, we do not believe that such receivables represent a credit risk because the related healthcare programs are funded by federal and state governments, and payment is primarily dependent upon submitting appropriate documentation.

Allowance for doubtful accounts

We assess the collectability of accounts receivable balances by considering factors such as historical collection experience, customer credit worthiness, the age of accounts receivable balances, regulatory changes and current economic conditions and trends that may affect a customer’s ability to pay. Actual results could differ from those estimates.

Equity-based compensation

Equity-based compensation. We measure the cost of services received in exchange for an award of equity instruments based on the grant-date fair value of the award. That cost is recognized in the Condensed Consolidated Statement of Operations over the period during which an employee is required to provide service in exchange for the award. We record excess tax benefits realized from the exercise of stock options as cash flows from operations.

Research and development expenses

Research and development expenses. Research and development expenses include external and internal expenses. External expenses include clinical and non-clinical activities performed by contract research organizations, lab services, purchases of drug and diagnostic product materials and manufacturing development costs. Research and development employee-related expenses include salaries, benefits and equity-based compensation expense. Other internal research and development expenses are incurred to support overall research and development activities and include expenses related to general overhead and facilities. We expense these costs in the period in which they are incurred. We estimate our liabilities for research and development expenses in order to match the recognition of expenses to the period in which the actual services are received. As such, accrued liabilities related to third party research and development activities are recognized based upon our estimate of services received and degree of completion of the services in accordance with the specific third party contract.

Research and development expense includes costs for in-process research and development projects acquired in asset acquisitions which have not reached technological feasibility, and which have no alternative future use. For in-process research and development projects acquired in business combinations, the in-process research and development project is capitalized and evaluated for impairment until the development process has been completed. Once the development process has been completed the asset will be amortized over its remaining estimated useful life.

Segment reporting

Segment reporting. Our chief operating decision-maker (“CODM”) is Phillip Frost, M.D., our Chairman and Chief Executive Officer. Our CODM reviews our operating results and operating plans and makes resource allocation decisions on a Company-wide or aggregate basis. We manage our operations in two reportable segments, pharmaceutical and diagnostics. The pharmaceutical segment consists of our pharmaceutical operations in Chile, Mexico, Ireland, Israel and Spain, Rayaldee product sales and our pharmaceutical research and development. The diagnostics segment primarily consists of clinical and genomics laboratory operations through BioReference and point-of-care operations. There are no significant inter-segment sales. We evaluate the performance of each segment based on operating profit or loss. There is no inter-segment allocation of interest expense or income taxes.

Foreign currency translation

Foreign currency translation. The financial statements of certain of our foreign operations are measured using the local currency as the functional currency. The local currency assets and liabilities are generally translated at the rate of exchange to the U.S. dollar on the balance sheet date and the local currency revenues and expenses are translated at average rates of exchange to the U.S. dollar during the reporting periods. Foreign currency transaction gains (losses) have been reflected as a component of Other income (expense), net within the Condensed Consolidated Statement of Operations and foreign currency translation gains (losses) have been included as a component of the Condensed Consolidated Statement of Comprehensive Income (Loss).

Variable interest entities

Variable interest entities. The consolidation of a variable interest entity (“VIE”) is required when an enterprise has a controlling financial interest. A controlling financial interest in a VIE will have both of the following characteristics: (a) the power to direct the activities of a VIE that most significantly impact the VIE’s economic performance and (b) the obligation to absorb losses of the VIE that could potentially be significant to the VIE.

Investments

Investments. We have made strategic investments in development stage and emerging companies. We record these investments as equity method investments or as equity securities based on our percentage of ownership and whether we have significant influence over the operations of the investees. For investments classified under the equity method of accounting, we record our proportionate share of their losses in Losses from investments in investees in our Condensed Consolidated Statement of Operations. Refer to Note 6. For investments classified as equity securities, we record changes in their fair value as Other income (expense) in our Condensed Consolidated Statement of Operations based on their closing price per share at the end of each reporting period, unless the equity security does not have a readily determinable fair value.

Recently adopted accounting pronouncements

Recently adopted accounting pronouncements.

In August 2020, the FASB issued ASU No. 2020-06, “Debt—Debt with Conversion and Other Options (Subtopic 470-20) and Derivatives and Hedging—Contracts in Entity's Own Equity (Subtopic 815-40).” ASU 2020-06 simplifies the accounting for convertible instruments by reducing the number of accounting models for convertible debt instruments and convertible preferred stock. The ASU is effective for public entities for fiscal years beginning after December 15, 2021, with early adoption permitted. As required, we adopted ASU 2020-06 on January 1, 2022 and used the modified retrospective approach for all convertible debt instruments at the beginning of the period of adoptions. Results for reporting periods beginning January 1, 2022 are presented under ASU 2020-06, while prior period amounts were not adjusted and continue to be reported in accordance with historic accounting guidance.

Under the modified approach, entities will apply the guidance to all financial instruments that are outstanding as of the beginning of the year of adoption with the cumulative effect recognized as an adjustment to the opening balance of retained earnings. ASU 2020-06 eliminates the cash conversion and beneficial conversion feature models in ASC 470-20 that require an issuer of certain convertible debt and preferred stock to separately account for embedded conversion features as a component of equity. The adoption of ASU 2020-06 at January 1, 2022 resulted in an increase of the Convertible notes of $21.6 million, a reduction of the Accumulated deficit of $17.5 million and a reduction of Additional paid-in capital of $39.1 million.

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Composition of Certain Financial Statement Captions (Tables)

6 Months Ended

Jun. 30, 2022

Organization, Consolidation and Presentation of Financial Statements [Abstract]

Composition of Certain Financial Statement Captions

(In thousands)	June 30, 2022		December 31, 2021
Accounts receivable, net:
Accounts receivable	$	165,226	$	261,476
Less: allowance for credit losses	(6,801)		(1,839)
	$	158,425	$	259,637
Inventories, net:
Consumable supplies	$	37,054	$	39,447
Finished products	42,321		44,107
Work in-process	1,892		1,615
Raw materials	7,256		6,112
Less: inventory reserve	(5,217)		(4,779)
	$	83,306	$	86,502
Other current assets and prepaid expenses:
Taxes recoverable	$	5,442	$	5,598
Prepaid expenses	12,324		10,641
Prepaid insurance	7,166		4,383
Other receivables	11,273		353
Other	6,358		6,195
	$	42,563	$	27,170
Intangible assets, net:
Customer relationships	$	311,864	$	314,823
Technologies	822,323		246,101
Trade names	49,735		49,770
Covenants not to compete	12,907		12,920
Licenses	5,873		5,766
Product registrations	6,440		6,995
Other	5,755		6,128
Less: accumulated amortization	(352,488)		(320,820)
	$	862,409	$	321,683
Accrued expenses:
Inventory received but not invoiced	$	18,853	$	40,446
Commitments and contingencies	12,745		27,819
Employee benefits	34,368		45,939
Contract liabilities	257		258
Clinical trials	4,245		4,867
Contingent consideration	487		487
Finance leases short-term	2,625		2,257
Professional fees	4,116		2,121
Other	50,558		69,299
	$	128,254	$	193,493

(In thousands)	June 30, 2022		December 31, 2021
Other long-term liabilities:
Contingent consideration	$	2,416	$	2,350
Mortgages and other debts payable	1,680		2,224
Finance leases long-term	4,588		2,924
Contract liabilities	192		208
Other	7,361		7,356
	$	16,237	$	15,062

Changes in Goodwill

The following table summarizes the changes in Goodwill by reporting unit during the six months ended June 30, 2022.

	2022
(In thousands)	Gross goodwill at January 1		Cumulative impairment at January 1		Acquisitions and dispositions		Foreign exchange and other		Balance at June 30
Pharmaceuticals
CURNA	$	4,827	$	(4,827)			$	—	$	—
Rayaldee	86,554		—				(6,652)		79,902
FineTech	11,698		(11,698)				—		—
ModeX	—		—		65,786		—		65,786
OPKO Biologics	139,784		—				—		139,784
OPKO Chile	3,760		—				(301)		3,459
OPKO Health Europe	7,478		—				(589)		6,889
OPKO Mexico	100		(100)				—		—
Transition Therapeutics	3,421		(3,421)				—		—
Diagnostics
BioReference	434,809		—		(151,784)		—		283,025
OPKO Diagnostics	17,977		(17,977)				—		—
	$	710,408	$	(38,023)	$	(85,998)	$	(7,542)	$	578,845

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Acquisitions and Investments (Tables)

6 Months Ended

Jun. 30, 2022

Business Combinations [Abstract]

Schedule of Preliminary Purchase Price Allocation and Estimated Fair Value of Assets Acquired and Liabilities Assumed

The following table summarizes the preliminary purchase price allocation and the estimated fair value of the net assets acquired and liabilities assumed at the date of acquisition. The purchase price allocation for the ModeX transaction is preliminary pending completion of the fair value analysis of acquired assets and liabilities:

(in thousands)	ModeX
Current assets
Cash and cash equivalents	$	218
Other assets	554
Property, plant and equipment	1,046
IPR&D assets	195,000
Goodwill	65,786
Accounts payable	(202)
Deferred tax liability	(40,740)
Total purchase price	$	221,662

Accounting Method, Carrying Value and Underlying Equity in Net Assets of Unconsolidated Investments

The following table reflects the accounting method, carrying value and underlying equity in net assets of our unconsolidated investments as of June 30, 2022 and December 31, 2021:

(in thousands)	As of June 30, 2022				As of December 31, 2021
Investment type	Investment Carrying Value		Underlying Equity in Net Assets		Investment Carrying Value		Underlying Equity in Net Assets
Equity method investments	$	173	$	4,822	$	263	$	3,577
Variable interest entity, equity method	797		2,417		816		3,043
Equity method investments - FV option	100,800				—
Equity securities	1,508				4,226
Equity securities with no readily determinable fair value	5,396				5,408
Warrants and options	11				16
Total carrying value of investments	$	108,685			$	10,729

Schedule of Net Gains and Losses on Equity Securities

Net gains and losses on our equity securities for the six months ended June 30, 2022, and 2021 were as follows:

	For the six months ended June 30
(in thousands)	2022		2021
Equity Securities:
Net gains and losses recognized during the period on equity securities	$	(2,718)	$	1,408
Less: Net gains realized during the period on equity securities	—		(2,981)
Unrealized net gains and losses recognized during the period on equity securities still held at the reporting date	$	(2,718)	$	(1,573)

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Debt (Tables)

6 Months Ended

Jun. 30, 2022

Debt Disclosure [Abstract]

Schedule of Debt

As of June 30, 2022 and December 31, 2021, our debt consisted of the following:

(In thousands)	June 30, 2022		December 31, 2021
2025 Notes	$	141,537	$	119,360
2023 Convertible Notes	66,889		65,525
2033 Senior Notes	3,050		3,050
JP Morgan Chase	2,867		—
Chilean and Spanish lines of credit	15,351		13,672
Current portion of notes payable	771		1,022
Long term portion of notes payable	1,984		2,642
Total	$	232,449	$	205,272
Balance sheet captions
Convertible Notes	$	211,477	$	187,935
Current portion of lines of credit and notes payable	18,989		14,695
LT notes payable included in long-term liabilities	1,984		2,642
Total	$	232,449	$	205,272

Schedule of Principal Amounts, Unamortized Discount and Net Carrying Amounts

The following table sets forth information related to the 2025 Notes which is included in our Condensed Consolidated Balance Sheet as of June 30, 2022:

(In thousands)	2025 Senior Notes		Discount		Debt Issuance Cost		Total
Balance at December 31, 2021	$	144,580	$	(22,747)	$	(2,473)	$	119,360
Amortization of debt discount and debt issuance costs	—		—		534		534
Adoption of ASU 2020-06	$	—	$	22,747	$	(1,104)	$	21,643
Balance at June 30, 2022	$	144,580	$	—	$	(3,043)	$	141,537

At June 30, 2022 and December 31, 2021, we had notes payable and other debt (excluding the 2033 Senior Notes, the 2023 Convertible Notes, the 2025 Notes, the Credit Agreement and amounts outstanding under lines of credit described above) as follows:

(In thousands)	June 30, 2022		December 31, 2021
Current portion of notes payable	$	771	$	1,022
Other long-term liabilities	1,984		2,642
Total	$	2,755	$	3,664

Summary of Lines of Credit

The following table summarizes the amounts outstanding under the BioReference, Chilean and Spanish lines of credit:

(Dollars in thousands)				Balance Outstanding
Lender	Interest rate on borrowings at June 30, 2022	Credit line capacity		June 30, 2022		December 31, 2021
JPMorgan Chase	3.25%	$	75,000	$	2,867	$	—
Itau Bank	5.50%	1,900		1,293		1,603
Bank of Chile	6.60%	2,500		1,452		1,048
BICE Bank	5.50%	2,500		1,499		850
Scotiabank	5.00%	5,500		1,560		567
Santander Bank	5.50%	5,000		2,467		503
Security Bank	5.50%	1,400		2		1,111
Estado Bank	5.50%	4,000		2,682		2,540
BCI Bank	5.00%	2,500		2,400		2,515
Corpbanca	5.00%	—		—		2,935
International Bank	5.50%	1,500		845		—
Consoorcio Bank	5.00%	2,000		1,151		—
Banco De Sabadell	1.75%	522		—		—
Santander Bank	2.15%	522		—		—
Total		$	104,844	$	18,218	$	13,672

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Accumulated Other Comprehensive Loss (Tables)

6 Months Ended

Jun. 30, 2022

Equity [Abstract]

Changes in Accumulated Other Comprehensive Loss, Net of Tax

For the six months ended June 30, 2022, changes in Accumulated other comprehensive loss, net of tax, were as follows:

(In thousands)	Foreign currency translation
Balance at December 31, 2021	$	(30,495)
Other comprehensive loss	(18,676)
Balance at June 30, 2022	$	(49,171)

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Fair Value Measurements (Tables)

6 Months Ended

Jun. 30, 2022

Fair Value Disclosures [Abstract]

Financial Assets and Liabilities Measured at Fair Value on a Recurring Basis

Our financial assets and liabilities measured at fair value on a recurring basis are as follows:

	Fair value measurements as of June 30, 2022
(In thousands)	Quoted prices in active markets for identical assets (Level 1)		Significant other observable inputs (Level 2)		Significant unobservable inputs (Level 3)		Total
Assets:
Money market funds	$	131,658	$	—	$	—	$	131,658
Equity securities	1,508		—		—		1,508
Equity Method - FV option	100,800		—		—		100,800
Common stock options/warrants	—		11		—		11
Forward contracts	—		434		—		434
Total assets	$	233,966	$	445	$	—	$	234,411
Liabilities:
Contingent consideration	—		—		2,903		2,903
Total liabilities	$	—	$	—	$	2,903	$	2,903

	Fair value measurements as of December 31, 2021
(In thousands)	Quoted prices in active markets for identical assets (Level 1)		Significant other observable inputs (Level 2)		Significant unobservable inputs (Level 3)		Total
Assets:
Equity securities	$	4,226	$	—	$	—	$	4,226
Common stock options/warrants	—		16		—		16
Forward contracts	—		122		—		122
Total assets	$	4,226	$	138	$	—	$	4,364
Liabilities:
Contingent consideration	—		—		2,837		2,837
Total liabilities	$	—	$	—	$	2,837	$	2,837

Carrying Amount and Estimated Fair Value of Long-Term Debt

The carrying amount and estimated fair value of our 2025 Notes, as well as the applicable fair value hierarchy tiers, are contained in the table below. The fair value of the 2025 Notes is determined using inputs other than quoted prices in active markets that are directly observable.

	June 30, 2022
(In thousands)	Carrying Value		Total Fair Value		Level 1		Level 2		Level 3
2025 Notes	$	141,537	$	145,163	$	—	$	145,163	$	—

Reconciliation of the Beginning and Ending Balances of Level 3 Assets

The following table reconciles the beginning and ending balances of our Level 3 assets and liabilities as of June 30, 2022:

	June 30, 2022
(In thousands)	Contingent consideration
Balance at December 31, 2021	$	2,837
Change in fair value:
Included in results of operations	69
Foreign currency impact	(3)
Balance at June 30, 2022	$	2,903

Reconciliation of the Beginning and Ending Balances of Level 3 Liabilities

The following table reconciles the beginning and ending balances of our Level 3 assets and liabilities as of June 30, 2022:

	June 30, 2022
(In thousands)	Contingent consideration
Balance at December 31, 2021	$	2,837
Change in fair value:
Included in results of operations	69
Foreign currency impact	(3)
Balance at June 30, 2022	$	2,903

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Derivative Contracts (Tables)

6 Months Ended

Jun. 30, 2022

Derivative Instruments and Hedging Activities Disclosure [Abstract]

Fair Values and Presentation of Derivative Financial Instruments

The following table summarizes the fair values and the presentation of our derivative financial instruments in the Condensed Consolidated Balance Sheets:

(In thousands)	Balance Sheet Component	June 30, 2022		December 31, 2021
Derivative financial instruments:
Common Stock options/warrants	Investments, net	$	11	$	16
Forward contracts	Unrealized gains on forward contracts are recorded in Other current assets and prepaid expenses. Unrealized (losses) on forward contracts are recorded in Accrued expenses.	$	434	$	122

Summary of Derivative Instrument Losses and Gains Recorded

The following table summarizes the losses and gains recorded for the three and six months ended June 30, 2022 and 2021:

	Three months ended June 30,				Six months ended June 30,
(In thousands)	2022		2021		2022		2021
Derivative gain (loss):
Common Stock options/warrants	$	(4)	$	(26)	$	(5)	$	(6)
Forward contracts	342		(246)		211		(705)
Total	$	338	$	(272)	$	206	$	(711)

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Revenue Recognition (Tables)

6 Months Ended

Jun. 30, 2022

Revenue from Contract with Customer [Abstract]

Schedule of Disaggregation of Revenue

The composition of revenue from services by payor for the three and six months ended June 30, 2022 and 2021 was as follows:

	Three months ended June 30,				Six months ended June 30,
(In thousands)	2022		2021		2022		2021
Healthcare insurers	$	76,442	$	109,084	$	172,269	$	273,913
Government payers	25,659		57,611		53,263		131,269
Client payers	80,931		225,936		240,021		488,845
Patients	3,772		4,566		7,849		10,122
Total	$	186,804	$	397,197	$	473,402	$	904,149

Schedule of Product Sales Allowances and Accruals

The following table presents an analysis of product sales allowances and accruals for the three and six months ended June 30, 2022 and 2021:

(In thousands)	Chargebacks, discounts, rebates and fees		Governmental		Returns		Total
Balance at March 31, 2022	$	1,588	$	5,282	$	2,333	$	9,203
Provision related to current period sales	3,411		5,442		308		9,161
Credits or payments made	(3,330)		(4,235)		(1,023)		(8,588)
Balance at June 30, 2022	$	1,669	$	6,489	$	1,618	$	9,776
Total gross Rayaldee sales							$	15,382
Provision for Rayaldee sales allowances and accruals as a percentage of gross Rayaldee sales							60%

(In thousands)	Chargebacks, discounts, rebates and fees		Governmental		Returns		Total
Balance at December 31, 2021	$	2,014	$	5,499	$	2,639	$	10,152
Provision related to current period sales	6,626		10,311		577		17,514
Credits or payments made	(6,971)		(9,321)		(1,598)		(17,890)
Balance at June 30, 2022	$	1,669	$	6,489	$	1,618	$	9,776
Total gross Rayaldee sales							$	28,861
Provision for Rayaldee sales allowances and accruals as a percentage of gross Rayaldee sales							61%

(In thousands)	Chargebacks, discounts, rebates and fees		Governmental		Returns		Total
Balance at March 31, 2021	$	1,693	$	6,209	$	3,487	$	11,389
Provision related to current period sales	3,724		7,061		322		11,107
Credits or payments made	(3,716)		(5,684)		(485)		(9,885)
Balance at June 30, 2021	$	1,701	$	7,586	$	3,324	$	12,611
Total gross Rayaldee sales							$	16,122
Provision for Rayaldee sales allowances and accruals as a percentage of gross Rayaldee sales							69%

(In thousands)	Chargebacks, discounts, rebates and fees		Governmental		Returns		Total
Balance at December 31, 2020	$	2,332	$	5,812	$	3,593	$	11,737
Provision related to current period sales	7,539		12,755		635		20,929
Credits or payments made	(8,170)		(10,981)		(904)		(20,055)
Balance at June 30, 2021	$	1,701	$	7,586	$	3,324	$	12,611
Total gross Rayaldee sales							$	31,767
Provision for Rayaldee sales allowances and accruals as a percentage of gross Rayaldee sales							66%

Changes in Contractual Liabilities Balance

Changes in the contractual liabilities balance during the six months ended June 30, 2022 are as follows:

(In thousands)
Balance at December 31, 2021	$	466
Balance at June 30, 2022	449
Revenue recognized in the period from:
Amounts included in contracts liability at the beginning of the period	17

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Segments (Tables)

6 Months Ended

Jun. 30, 2022

Segment Reporting [Abstract]

Operations and Assets for Operating Segments and Geographic Information

Information regarding our operations and assets for our operating segments and the unallocated corporate operations as well as geographic information are as follows:

	For the three months ended June 30,				For the six months ended June 30,
(In thousands)	2022		2021		2022		2021
Revenue from services:
Pharmaceutical	$	—	$	—	$	—	$	—
Diagnostics	186,804		397,197		473,402		904,149
Corporate	—		—		—		—
	$	186,804	$	397,197	$	473,402	$	904,149
Revenue from products:
Pharmaceutical	$	35,892	$	35,663	$	72,550	$	69,608
Diagnostics	—		—		—		—
Corporate	—		—		—		—
	$	35,892	$	35,663	$	72,550	$	69,608
Revenue from transfer of intellectual property and other:
Pharmaceutical	$	87,197	$	9,548	$	93,159	$	13,816
Diagnostics	—		—		—		—
Corporate	—		—		—		—
	$	87,197	$	9,548	$	93,159	$	13,816
Operating income (loss):
Pharmaceutical	$	55,435	$	(13,710)	$	37,327	$	(32,868)
Diagnostics	(57,543)		30,000		(101,092)		97,014
Corporate	(8,631)		(10,719)		(19,399)		(20,138)
	$	(10,739)	$	5,571	$	(83,164)	$	44,008
Depreciation and amortization:
Pharmaceutical	$	17,840	$	7,007	$	33,242	$	14,420
Diagnostics	10,155		13,566		22,567		26,141
Corporate	—		—		—		—
	$	27,995	$	20,573	$	55,809	$	40,561
Loss from investment in investees:
Pharmaceutical	$	(268)	$	(67)	$	(316)	$	(110)
Diagnostics	—		—		—		—
Corporate	—		—		—		—
	$	(268)	$	(67)	$	(316)	$	(110)
Revenues:
United States	$	193,105	$	402,291	$	484,913	$	915,163
Ireland	89,177		12,088		97,638		19,218
Chile	15,804		18,657		32,143		32,809
Spain	5,696		5,437		12,805		11,356
Israel	1,854		724		3,412		3,235
Mexico	4,055		3,039		7,805		5,457
Other	202		172		395		335
	$	309,893	$	442,408	$	639,111	$	987,573

(In thousands)	June 30, 2022		December 31, 2021
Assets:
Pharmaceutical	$	1,354,058	$	1,114,460
Diagnostics	748,165		1,238,583
Corporate	267,379		46,672
	$	2,369,602	$	2,399,715
Goodwill:
Pharmaceutical	$	295,820	$	237,576
Diagnostics	283,025		283,025
	$	578,845	$	520,601

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Leases (Tables)

6 Months Ended

Jun. 30, 2022

Leases [Abstract]

Lease Assets and Liabilities

The following table presents the lease balances within the Condensed Consolidated Balance Sheet as of June 30, 2022 and December 31, 2021:

(in thousands)	Classification on the Balance Sheet	June 30, 2022			December 31, 2021
Assets
Operating lease assets	Operating lease right-of-use assets	$	42,412		$	44,228
Finance lease assets	Property, plant and equipment, net	7,213			5,181
Liabilities
Current
Operating lease liabilities	Current maturities of operating leases	12,122			11,624
Accrued expenses	Current maturities of finance leases	2,625			2,257
Long-term
Operating lease liabilities	Operating lease liabilities	30,876			33,097
Other long-term liabilities	Finance lease liabilities	$	4,588		$	2,924
Weighted average remaining lease term
Operating leases		6.4 years			7.2 years
Finance leases		3.2 years			2.4 years
Weighted average discount rate
Operating leases		3.7		%	4.6		%
Finance leases		7.0		%	4.8		%

Lease Liability Maturity

The following table reconciles the undiscounted future minimum lease payments (displayed by year and in the aggregate) under noncancelable operating leases with terms of more than one year to the total operating lease liabilities recognized on our Condensed Consolidated Balance Sheet as of June 30, 2022:

(in thousands)	Operating		Finance
July 1, 2022 through December 31, 2022	$	6,322	$	1,528
2023	10,399		2,430
2024	7,025		1,829
2025	4,541		1,291
2026	3,654		636
Thereafter	15,493		2
Total undiscounted future minimum lease payments	47,434		7,716
Less: Difference between lease payments and discounted lease liabilities	4,436		503
Total lease liabilities	$	42,998	$	7,213

Lease Liability Maturity

The following table reconciles the undiscounted future minimum lease payments (displayed by year and in the aggregate) under noncancelable operating leases with terms of more than one year to the total operating lease liabilities recognized on our Condensed Consolidated Balance Sheet as of June 30, 2022:

(in thousands)	Operating		Finance
July 1, 2022 through December 31, 2022	$	6,322	$	1,528
2023	10,399		2,430
2024	7,025		1,829
2025	4,541		1,291
2026	3,654		636
Thereafter	15,493		2
Total undiscounted future minimum lease payments	47,434		7,716
Less: Difference between lease payments and discounted lease liabilities	4,436		503
Total lease liabilities	$	42,998	$	7,213

Lease Cash Flow Information

Supplemental cash flow information is as follows:

(in thousands)	For the six months ended June 30,
	2022		2021
Operating cash out flows from operating leases	$	8,327	$	6,484
Operating cash out flows from finance leases	52		45
Financing cash out flows from finance leases	724		769
Total	$	9,103	$	7,298

XML

Business and Organization (Details) $ / shares in Units, $ in Thousands			3 Months Ended		6 Months Ended
	May 09, 2022 USD ($) $ / shares shares	Apr. 29, 2022 USD ($) $ / shares shares	Jun. 30, 2022 USD ($) $ / shares	Jun. 30, 2021 USD ($)	Jun. 30, 2022 USD ($) employee $ / shares	Jun. 30, 2021 USD ($)	Dec. 31, 2021 $ / shares
Income Statement, Balance Sheet and Additional Disclosures by Disposal Groups, Including Discontinued Operations [Line Items]
Number of sales employees | employee					250
Common stock, par value (in dollars per share) | $ / shares			$ 0.01		$ 0.01		$ 0.01
Value of consideration shares					$ 172,000	$ 0
Gain on sale of GeneDx			$ 15,365	$ 0	$ 15,365	$ 0
Common Stock
Income Statement, Balance Sheet and Additional Disclosures by Disposal Groups, Including Discontinued Operations [Line Items]
Stock price (in dollars per share) | $ / shares	$ 2.44
ModeX Therapeutics Inc
Income Statement, Balance Sheet and Additional Disclosures by Disposal Groups, Including Discontinued Operations [Line Items]
Total aggregate consideration	$ 300,000
Common stock, par value (in dollars per share) | $ / shares	$ 0.01
Shares deposited in escrow (as a percent)	10.00%
Escrow deposit, term	12 months
Business acquisition, equity awards issued	$ 12,400
Equity interest issued or issuable, period following closing date	4 years
Escrow Period	4 years
Lockup and voting agreement, period following closing date	4 years
Consideration shares (as a percent)	88.00%
ModeX Therapeutics Inc | Former Stockholder
Income Statement, Balance Sheet and Additional Disclosures by Disposal Groups, Including Discontinued Operations [Line Items]
Business acquisition, equity awards issued	$ 2,600
ModeX Therapeutics Inc | Common Stock
Income Statement, Balance Sheet and Additional Disclosures by Disposal Groups, Including Discontinued Operations [Line Items]
Number of shares issued in business combination (in shares) | shares	89,907,310
Value of consideration shares	$ 219,400
Stock price (in dollars per share) | $ / shares	$ 2.44
Detect Genomix | Milestone Consideration, Tranche One
Income Statement, Balance Sheet and Additional Disclosures by Disposal Groups, Including Discontinued Operations [Line Items]
Shareholder agreement, extension period		1 year
Detect Genomix | Milestone Consideration, Tranche Two
Income Statement, Balance Sheet and Additional Disclosures by Disposal Groups, Including Discontinued Operations [Line Items]
Shareholder agreement, extension period		6 months
Detect Genomix | Sema4
Income Statement, Balance Sheet and Additional Disclosures by Disposal Groups, Including Discontinued Operations [Line Items]
Total aggregate consideration		$ 447,000
Number of shares issued in business combination (in shares) | shares		80,000,000
Payments to acquire business		$ 150,000
Additional revenue-based milestones		150,000
Total upfront consideration transferred		$ 322,000
Gain on sale of GeneDx			$ 15,400
Outstanding shares held (as a percent)		5.00%
Detect Genomix | Sema4 | Common Class A
Income Statement, Balance Sheet and Additional Disclosures by Disposal Groups, Including Discontinued Operations [Line Items]
Common stock, par value (in dollars per share) | $ / shares		$ 0.0001

XML

Impact of COVID-19 (Details) $ in Millions	6 Months Ended
	Jun. 30, 2022 USD ($)
Routine Clinical Test
Unusual or Infrequent Item, or Both [Line Items]
Change in testing volume (as a percent)	26.20%
Services
Unusual or Infrequent Item, or Both [Line Items]
Increase (decrease) in revenue	$ (430.7)
COVID-19 Testing | COVID-19 Testing Revenue Concentration Risk | Revenue Benchmark
Unusual or Infrequent Item, or Both [Line Items]
Concentration risk (as a percent)	5.70%
COVID-19 Testing | COVID-19 Testing Revenue Concentration Risk | Accounts Receivable
Unusual or Infrequent Item, or Both [Line Items]
Concentration risk (as a percent)	2.00%

XML

Summary of Significant Accounting Policies (Details) $ in Thousands			3 Months Ended			6 Months Ended
	Jun. 30, 2022 USD ($)	Dec. 31, 2021 USD ($)	Jun. 30, 2022 USD ($)	Mar. 31, 2022 USD ($)	Jun. 30, 2021 USD ($)	Jun. 30, 2022 USD ($) segment	Jun. 30, 2021 USD ($)	Jan. 01, 2022 USD ($)	Mar. 31, 2021 USD ($)	Dec. 31, 2020 USD ($)
Summary of Significant Accounting Policies [Line Items]
Provision for inventory obsolescence			$ 300		$ 900	$ 1,000	$ 3,900
Goodwill, in-process research and development and other intangible assets acquired	$ 1,600,000	$ 1,400,000	1,600,000			1,600,000
Goodwill	578,845	520,601	578,845			578,845		$ 710,408
Net intangible assets other than goodwill	1,057,400	911,900	1,057,400			1,057,400
Intangible assets, net	862,409	321,683	862,409			862,409
In-process research and development	195,000	590,200	195,000			195,000
Amortization expense			22,793		12,574	44,818	25,151
Depreciation expense			5,200		8,000	11,000	15,400
Allowance for credit losses	6,801	1,839	6,801			6,801
Provision related to current period sales			100		300	200	600
Equity-based compensation expense			4,300		3,500	$ 11,900	6,100
Number of reportable segments | segment						2
Foreign currency transaction gains (losses)			800		(400)	$ 1,800	4,400
Equity	1,718,799	1,685,126	1,718,799	$ 1,614,884	1,742,585	1,718,799	1,742,585		$ 1,696,514	$ 1,671,551
Retained Earnings
Summary of Significant Accounting Policies [Line Items]
Equity	(1,651,601)	(1,511,976)	(1,651,601)	(1,549,951)	(1,466,941)	(1,651,601)	(1,466,941)		(1,450,755)	(1,481,833)
Additional Paid-in Capital
Summary of Significant Accounting Policies [Line Items]
Equity	$ 3,413,556	3,222,487	3,413,556	3,191,139	$ 3,214,351	$ 3,413,556	$ 3,214,351		$ 3,155,648	$ 3,152,694
Cumulative Effect, Period of Adoption, Adjustment
Summary of Significant Accounting Policies [Line Items]
Equity		(21,642)						21,600
Cumulative Effect, Period of Adoption, Adjustment | Retained Earnings
Summary of Significant Accounting Policies [Line Items]
Equity		17,458						17,500
Cumulative Effect, Period of Adoption, Adjustment | Additional Paid-in Capital
Summary of Significant Accounting Policies [Line Items]
Equity		(39,100)						$ (39,100)
In Process Research and Development
Summary of Significant Accounting Policies [Line Items]
Intangible assets, net				$ 590,000
Intangible assets, estimated useful lives				12 years
Detect Genomix
Summary of Significant Accounting Policies [Line Items]
Goodwill		$ 151,800
OPKO Biologics
Summary of Significant Accounting Policies [Line Items]
In-process research and development				$ 590,000
Minimum
Summary of Significant Accounting Policies [Line Items]
Intangible assets, estimated useful lives						3 years
Maximum
Summary of Significant Accounting Policies [Line Items]
Intangible assets, estimated useful lives						20 years
Credit Concentration Risk | Accounts Receivable | Federal and State Governments
Summary of Significant Accounting Policies [Line Items]
Concentration percentage	12.00%	6.00%
Geographic Concentration Risk | Accounts Receivable | States, Cities and Other Municipalities
Summary of Significant Accounting Policies [Line Items]
Concentration percentage	3.90%	4.10%
Customer Concentration Risk | Accounts Receivable | Individual Patients
Summary of Significant Accounting Policies [Line Items]
Concentration percentage	2.30%	0.70%
Software
Summary of Significant Accounting Policies [Line Items]
Property, plant and equipment, estimated useful lives						3 years
Machinery, Medical and Other Equipment | Minimum
Summary of Significant Accounting Policies [Line Items]
Property, plant and equipment, estimated useful lives						5 years
Machinery, Medical and Other Equipment | Maximum
Summary of Significant Accounting Policies [Line Items]
Property, plant and equipment, estimated useful lives						8 years
Furniture and Fixtures | Minimum
Summary of Significant Accounting Policies [Line Items]
Property, plant and equipment, estimated useful lives						5 years
Furniture and Fixtures | Maximum
Summary of Significant Accounting Policies [Line Items]
Property, plant and equipment, estimated useful lives						12 years
Buildings and Improvements | Minimum
Summary of Significant Accounting Policies [Line Items]
Property, plant and equipment, estimated useful lives						10 years
Buildings and Improvements | Maximum
Summary of Significant Accounting Policies [Line Items]
Property, plant and equipment, estimated useful lives						40 years
Automobiles and Aircraft | Minimum
Summary of Significant Accounting Policies [Line Items]
Property, plant and equipment, estimated useful lives						3 years
Automobiles and Aircraft | Maximum
Summary of Significant Accounting Policies [Line Items]
Property, plant and equipment, estimated useful lives						5 years
In Process Research and Development
Summary of Significant Accounting Policies [Line Items]
Net intangible assets other than goodwill	$ 195,000	$ 590,200	$ 195,000			$ 195,000

XML

Earnings (Loss) Per Share (Details) - shares	3 Months Ended		6 Months Ended
	Jun. 30, 2022	Jun. 30, 2021	Jun. 30, 2022	Jun. 30, 2021
Antidilutive Securities Excluded from Computation of Earnings Per Share [Line Items]
Number of warrant and options exercised (in shares)	789,063	63,625	844,813	181,125
Number of common stock issued for stock warrant and stock options exercised (in shares)	546,337	63,625	602,087	181,125
Shares surrendered in lieu of cash payment (in shares)	242,726	0	242,726	0
Common Stock
Antidilutive Securities Excluded from Computation of Earnings Per Share [Line Items]
Dilutive potential shares (in shares)	56,605,791	64,292,882	57,016,847	69,861,689

XML

Composition of Certain Financial Statement Captions (Details) - USD ($) $ in Thousands	Jun. 30, 2022	Dec. 31, 2021
Accounts receivable, net:
Accounts receivable	$ 165,226	$ 261,476
Less: allowance for credit losses	(6,801)	(1,839)
Accounts receivable, net	158,425	259,637
Inventories, net:
Consumable supplies	37,054	39,447
Finished products	42,321	44,107
Work in-process	1,892	1,615
Raw materials	7,256	6,112
Less: inventory reserve	(5,217)	(4,779)
Inventory, net	83,306	86,502
Other current assets and prepaid expenses:
Taxes recoverable	5,442	5,598
Prepaid expenses	12,324	10,641
Prepaid insurance	7,166	4,383
Other receivables	11,273	353
Other	6,358	6,195
Other current assets and prepaid expenses	42,563	27,170
Intangible assets, net:
Less: accumulated amortization	(352,488)	(320,820)
Intangible assets, net	862,409	321,683
Accrued expenses:
Inventory received but not invoiced	18,853	40,446
Commitments and contingencies	12,745	27,819
Employee benefits	34,368	45,939
Contract liabilities	257	258
Clinical trials	4,245	4,867
Contingent consideration	487	487
Finance leases short-term	2,625	2,257
Professional fees	4,116	2,121
Other	50,558	69,299
Accrued expenses	128,254	193,493
Other long-term liabilities:
Contingent consideration	2,416	2,350
Mortgages and other debts payable	1,680	2,224
Finance leases long-term	4,588	2,924
Contract liabilities	192	208
Other	7,361	7,356
Other long-term liabilities	16,237	15,062
Customer relationships
Intangible assets, net:
Intangible assets	311,864	314,823
Technologies
Intangible assets, net:
Intangible assets	822,323	246,101
Trade names
Intangible assets, net:
Intangible assets	49,735	49,770
Covenants not to compete
Intangible assets, net:
Intangible assets	12,907	12,920
Licenses
Intangible assets, net:
Intangible assets	5,873	5,766
Product registrations
Intangible assets, net:
Intangible assets	6,440	6,995
Other
Intangible assets, net:
Intangible assets	$ 5,755	$ 6,128

XML

Composition of Certain Financial Statement Captions - Narrative (Details) - USD ($) $ in Thousands	3 Months Ended	6 Months Ended
	Mar. 31, 2022	Jun. 30, 2022	Jan. 01, 2022	Dec. 31, 2021
Acquired Finite-Lived Intangible Assets [Line Items]
Goodwill		$ 578,845	$ 710,408	$ 520,601
Intangible assets, net		862,409		321,683
In-Process Research and Development		$ (195,000)		(590,200)
Detect Genomix
Acquired Finite-Lived Intangible Assets [Line Items]
Goodwill				$ 151,800
OPKO Biologics
Acquired Finite-Lived Intangible Assets [Line Items]
In-Process Research and Development	$ (590,000)
Covenants not to compete
Acquired Finite-Lived Intangible Assets [Line Items]
Useful life		5 years
In Process Research and Development
Acquired Finite-Lived Intangible Assets [Line Items]
Intangible assets, net	$ 590,000
Intangible assets, estimated useful lives	12 years
Minimum
Acquired Finite-Lived Intangible Assets [Line Items]
Intangible assets, estimated useful lives		3 years
Minimum | Technologies
Acquired Finite-Lived Intangible Assets [Line Items]
Useful life		7 years
Minimum | Customer relationships
Acquired Finite-Lived Intangible Assets [Line Items]
Useful life		7 years
Minimum | Products
Acquired Finite-Lived Intangible Assets [Line Items]
Useful life		7 years
Minimum | Trade names
Acquired Finite-Lived Intangible Assets [Line Items]
Useful life		5 years
Minimum | Other
Acquired Finite-Lived Intangible Assets [Line Items]
Useful life		9 years
Maximum
Acquired Finite-Lived Intangible Assets [Line Items]
Intangible assets, estimated useful lives		20 years
Maximum | Technologies
Acquired Finite-Lived Intangible Assets [Line Items]
Useful life		17 years
Maximum | Customer relationships
Acquired Finite-Lived Intangible Assets [Line Items]
Useful life		20 years
Maximum | Products
Acquired Finite-Lived Intangible Assets [Line Items]
Useful life		10 years
Maximum | Trade names
Acquired Finite-Lived Intangible Assets [Line Items]
Useful life		10 years
Maximum | Other
Acquired Finite-Lived Intangible Assets [Line Items]
Useful life		13 years

XML

Composition of Certain Financial Statement Captions - Changes in Goodwill (Details) - USD ($) $ in Thousands	6 Months Ended
	Jun. 30, 2022	May 09, 2022	Jan. 01, 2022	Dec. 31, 2021
Goodwill [Roll Forward]
Goodwill, beginning balance	$ 578,845		$ 710,408	$ 520,601
Cumulative impairment at January 1				(38,023)
Acquisitions and dispositions	(85,998)
Foreign exchange and other	(7,542)
Goodwill, ending balance	578,845		710,408	520,601
ModeX
Goodwill [Roll Forward]
Goodwill, beginning balance		$ 65,786
Goodwill, ending balance		$ 65,786
BioReference
Goodwill [Roll Forward]
Goodwill, beginning balance	283,000
Goodwill, ending balance	283,000
Pharmaceuticals | CURNA
Goodwill [Roll Forward]
Goodwill, beginning balance	0		4,827
Cumulative impairment at January 1				(4,827)
Acquisitions and dispositions
Foreign exchange and other	0
Goodwill, ending balance	0		4,827
Pharmaceuticals | Rayaldee
Goodwill [Roll Forward]
Goodwill, beginning balance	79,902		86,554
Cumulative impairment at January 1				0
Acquisitions and dispositions
Foreign exchange and other	(6,652)
Goodwill, ending balance	79,902		86,554
Pharmaceuticals | FineTech
Goodwill [Roll Forward]
Goodwill, beginning balance	0		11,698
Cumulative impairment at January 1				(11,698)
Acquisitions and dispositions
Foreign exchange and other	0
Goodwill, ending balance	0		11,698
Pharmaceuticals | ModeX
Goodwill [Roll Forward]
Goodwill, beginning balance	65,786		0
Cumulative impairment at January 1				0
Acquisitions and dispositions	65,786
Foreign exchange and other	0
Goodwill, ending balance	65,786		0
Pharmaceuticals | OPKO Biologics
Goodwill [Roll Forward]
Goodwill, beginning balance	139,784		139,784
Cumulative impairment at January 1				0
Acquisitions and dispositions
Foreign exchange and other	0
Goodwill, ending balance	139,784		139,784
Pharmaceuticals | OPKO Chile
Goodwill [Roll Forward]
Goodwill, beginning balance	3,459		3,760
Cumulative impairment at January 1				0
Acquisitions and dispositions
Foreign exchange and other	(301)
Goodwill, ending balance	3,459		3,760
Pharmaceuticals | OPKO Health Europe
Goodwill [Roll Forward]
Goodwill, beginning balance	6,889		7,478
Cumulative impairment at January 1				0
Acquisitions and dispositions
Foreign exchange and other	(589)
Goodwill, ending balance	6,889		7,478
Pharmaceuticals | OPKO Mexico
Goodwill [Roll Forward]
Goodwill, beginning balance	0		100
Cumulative impairment at January 1				(100)
Acquisitions and dispositions
Foreign exchange and other	0
Goodwill, ending balance	0		100
Pharmaceuticals | Transition Therapeutics
Goodwill [Roll Forward]
Goodwill, beginning balance	0		3,421
Cumulative impairment at January 1	(3,421)
Acquisitions and dispositions
Foreign exchange and other	0
Goodwill, ending balance	0		3,421
Diagnostics | BioReference
Goodwill [Roll Forward]
Goodwill, beginning balance	283,025		434,809
Cumulative impairment at January 1				0
Acquisitions and dispositions	(151,784)
Foreign exchange and other	0
Goodwill, ending balance	283,025		434,809
Diagnostics | OPKO Diagnostics
Goodwill [Roll Forward]
Goodwill, beginning balance	0		17,977
Cumulative impairment at January 1				$ (17,977)
Acquisitions and dispositions
Foreign exchange and other	0
Goodwill, ending balance	$ 0		$ 17,977

XML

Acquisitions and Investments - Narrative (Details) - USD ($) $ / shares in Units, $ in Thousands				2 Months Ended	3 Months Ended		6 Months Ended		12 Months Ended
	May 09, 2022	Apr. 29, 2022	Sep. 14, 2021	Jun. 30, 2022	Jun. 30, 2022	Jun. 30, 2021	Jun. 30, 2022	Jun. 30, 2021	Dec. 31, 2021
Schedule of Equity Method Investments [Line Items]
Value of consideration shares							$ 172,000	$ 0
Total assets of equity method investees				$ 2,369,602	$ 2,369,602		2,369,602		$ 2,399,715
Total liabilities of equity method investees				650,803	650,803		650,803		714,589
Market value				1,900	1,900		1,900		4,500
Upfront payment received					309,893	$ 442,408	639,111	987,573
Transfer of intellectual property and other
Schedule of Equity Method Investments [Line Items]
Upfront payment received					87,197	$ 9,548	93,159	$ 13,816
LeaderMed | LeaderMed Joint Venture | Corporate Joint Venture
Schedule of Equity Method Investments [Line Items]
Joint venture (in shares)			4,703
Ownership interest in joint venture (as a percent)			47.00%
LeaderMed | LeaderMed Joint Venture | Corporate Joint Venture | Transfer of intellectual property and other
Schedule of Equity Method Investments [Line Items]
Upfront payment received			$ 1,000						1,000
Equity Method Investment, Nonconsolidated Investee or Group of Investees
Schedule of Equity Method Investments [Line Items]
Total assets of equity method investees				212,400	212,400		212,400		223,600
Total liabilities of equity method investees				$ 41,700	$ 41,700		41,700		37,900
Net losses of equity method investees							$ 48,600		$ 69,400
Pharmsynthez
Schedule of Equity Method Investments [Line Items]
Equity method investments (as a percent)				9.00%	9.00%		9.00%
Cocrystal
Schedule of Equity Method Investments [Line Items]
Equity method investments (as a percent)				3.00%	3.00%		3.00%
Number of shares into which warrants may be converted (in shares)				33,000	33,000		33,000
Non-Invasive Monitoring Systems, Inc.
Schedule of Equity Method Investments [Line Items]
Equity method investments (as a percent)				1.00%	1.00%		1.00%
Neovasc
Schedule of Equity Method Investments [Line Items]
Equity method investments (as a percent)				1.00%	1.00%		1.00%
BioCardia, Inc.
Schedule of Equity Method Investments [Line Items]
Equity method investments (as a percent)				1.00%	1.00%		1.00%
Equity security investments (as a percent)				1.00%	1.00%		1.00%
Number of shares into which warrants may be converted (in shares)				47,000	47,000		47,000		47,000
Xenetic Biosciences, Inc.
Schedule of Equity Method Investments [Line Items]
Equity method investments (as a percent)				3.00%	3.00%		3.00%
LeaderMed
Schedule of Equity Method Investments [Line Items]
Stock ownership (as a percent)							47.00%
Sema4
Schedule of Equity Method Investments [Line Items]
Net losses for fair value changes in investment		$ 71,200
Phio Pharmaceuticals
Schedule of Equity Method Investments [Line Items]
Equity security investments (as a percent)				0.01%	0.01%		0.01%
VBI Vaccines Inc
Schedule of Equity Method Investments [Line Items]
Equity security investments (as a percent)				1.00%	1.00%		1.00%
ChromaDex
Schedule of Equity Method Investments [Line Items]
Equity security investments (as a percent)				0.10%	0.10%		0.10%
Eloxx Pharmaceuticals
Schedule of Equity Method Investments [Line Items]
Equity security investments (as a percent)				1.00%	1.00%		1.00%
CAMP4
Schedule of Equity Method Investments [Line Items]
Equity security investments (as a percent)				2.00%	2.00%		2.00%
HealthSnap
Schedule of Equity Method Investments [Line Items]
Equity security investments (as a percent)				7.00%	7.00%		7.00%
InCellDx, Inc
Schedule of Equity Method Investments [Line Items]
Equity method investments (as a percent)				29.00%	29.00%		29.00%
Number of shares into which warrants may be converted (in shares)				700,000	700,000		700,000
Zebra
Schedule of Equity Method Investments [Line Items]
Stock ownership (as a percent)							29.00%
Zebra | Variable Interest Entity, Not Primary Beneficiary
Schedule of Equity Method Investments [Line Items]
Equity method investments (as a percent)				29.00%	29.00%		29.00%
Series A Preferred Stock | Zebra | Variable Interest Entity, Not Primary Beneficiary
Schedule of Equity Method Investments [Line Items]
Investment owned (in shares)				1,260,000	1,260,000		1,260,000
Restricted Stock | Zebra | Variable Interest Entity, Not Primary Beneficiary
Schedule of Equity Method Investments [Line Items]
Shares received as a gift (in shares)							900,000
Common Stock
Schedule of Equity Method Investments [Line Items]
Stock price (in dollars per share)	$ 2.44
Sema4 | Sema4
Schedule of Equity Method Investments [Line Items]
Equity method investments (as a percent)				21.20%	21.20%		21.20%
Sema4 | Common Class A
Schedule of Equity Method Investments [Line Items]
Investment owned (in shares)				80,000,000	80,000,000		80,000,000
ModeX Therapeutics Inc
Schedule of Equity Method Investments [Line Items]
Total aggregate consideration	$ 300,000
Total purchase price	221,662
Vested equity awards	2,300
Revenue				$ 0
Net income (loss)				$ 1,100
ModeX Therapeutics Inc | Common Stock
Schedule of Equity Method Investments [Line Items]
Value of consideration shares	$ 219,400
Stock price (in dollars per share)	$ 2.44
Detect Genomix | Sema4
Schedule of Equity Method Investments [Line Items]
Total aggregate consideration		447,000
Payments to acquire business		$ 150,000
Outstanding shares held (as a percent)		5.00%

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Acquisitions and Investments - Schedule of Preliminary Purchase Price Allocation and Estimated Fair Value of Assets Acquired and Liabilities Assumed (Details) - USD ($) $ in Thousands	Jun. 30, 2022	May 09, 2022	Jan. 01, 2022	Dec. 31, 2021
Business Acquisition [Line Items]
Goodwill	$ 578,845		$ 710,408	$ 520,601
ModeX Therapeutics Inc
Business Acquisition [Line Items]
Cash and cash equivalents		$ 218
Other assets		554
Property, plant and equipment		1,046
Goodwill		65,786
Accounts payable		(202)
Deferred tax liability		(40,740)
Total purchase price		221,662
ModeX Therapeutics Inc | In Process Research and Development
Business Acquisition [Line Items]
IPR&D assets		$ 195,000

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Acquisitions and Investments - Summary of Investments (Details) - USD ($) $ in Thousands	Jun. 30, 2022	Dec. 31, 2021
Investment Carrying Value
Equity method investments	$ 173	$ 263
Variable interest entity, equity method	797	816
Equity method investments - FV option	100,800	0
Equity securities	1,508	4,226
Equity securities with no readily determinable fair value	5,396	5,408
Warrants and options	11	16
Total carrying value of investments	108,685	10,729
Underlying Equity in Net Assets
Equity method investment, underlying equity in net assets	4,822	3,577
Variable interest entity, equity method, underlying equity in net assets	$ 2,417	$ 3,043

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Acquisitions and Investments - Schedule of Net Gains and Losses on Equity Securities (Details) - USD ($) $ in Thousands	6 Months Ended
	Jun. 30, 2022	Jun. 30, 2021
Equity Securities:
Net gains and losses recognized during the period on equity securities	$ (2,718)	$ 1,408
Less: Net gains realized during the period on equity securities	0	(2,981)
Unrealized net gains and losses recognized during the period on equity securities still held at the reporting date	$ (2,718)	$ (1,573)

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Debt - Schedule of Debt (Details) - USD ($) $ in Thousands	Jun. 30, 2022	Dec. 31, 2021	Feb. 01, 2019
Debt Instrument [Line Items]
Long-term debt	$ 232,449	$ 205,272
Convertible Notes
Debt Instrument [Line Items]
Long-term debt	211,477	187,935
Current portion of lines of credit and notes payable
Debt Instrument [Line Items]
Long-term debt	18,989	14,695
LT notes payable included in long-term liabilities
Debt Instrument [Line Items]
Long-term debt	1,984	2,642
Line of Credit
Debt Instrument [Line Items]
Long-term debt	15,351	13,672
Notes Payable, Other Payables
Debt Instrument [Line Items]
Long-term debt, current maturities	771	1,022
Long-term debt, excluding current maturities	1,984	2,642
Convertible Senior Notes Due 2025 | Convertible Debt
Debt Instrument [Line Items]
Long-term debt	141,537	119,360
5% Convertible Notes | Convertible Debt
Debt Instrument [Line Items]
Long-term debt	66,889	65,525
Notes Due February 1, 2033 | Notes
Debt Instrument [Line Items]
Long-term debt	$ 3,050	$ 3,050	$ 3,000

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Debt - Narrative (Details)		1 Months Ended					6 Months Ended		12 Months Ended	48 Months Ended
	Jan. 30, 2013 USD ($)	May 31, 2021 USD ($) shares	Feb. 28, 2019 USD ($) day $ / shares shares	Feb. 28, 2018 USD ($) $ / shares	Nov. 30, 2015 USD ($)	Jan. 31, 2013	Jun. 30, 2022 USD ($) day institution shares	Jun. 30, 2021 USD ($)	Dec. 31, 2021 USD ($) institution shares	Dec. 31, 2016 USD ($) shares	Mar. 31, 2022 USD ($)	Jan. 01, 2022 USD ($)	Mar. 31, 2021 USD ($)	Dec. 31, 2020 USD ($)	Feb. 01, 2019 USD ($)
Debt Instrument [Line Items]
Converted debt amount							$ 0	$ 68,775,000
Loss on conversion of the 2025 Notes							0	11,111,000
Equity							1,718,799,000	1,742,585,000	$ 1,685,126,000		$ 1,614,884,000		$ 1,696,514,000	$ 1,671,551,000
Remaining principal							232,449,000		205,272,000
Credit line capacity							104,844,000
Goodwill							$ 578,845,000		$ 520,601,000			$ 710,408,000
Number of financial institutions | institution							13		11
Retained Earnings
Debt Instrument [Line Items]
Equity							$ (1,651,601,000)	(1,466,941,000)	$ (1,511,976,000)		(1,549,951,000)		(1,450,755,000)	(1,481,833,000)
Additional Paid-in Capital
Debt Instrument [Line Items]
Equity							3,413,556,000	$ 3,214,351,000	3,222,487,000		$ 3,191,139,000		$ 3,155,648,000	$ 3,152,694,000
Cumulative Effect, Period of Adoption, Adjustment
Debt Instrument [Line Items]
Equity									(21,642,000)			21,600,000
Cumulative Effect, Period of Adoption, Adjustment | Retained Earnings
Debt Instrument [Line Items]
Equity									17,458,000			17,500,000
Cumulative Effect, Period of Adoption, Adjustment | Additional Paid-in Capital
Debt Instrument [Line Items]
Equity									$ (39,100,000)			$ (39,100,000)
BioReference
Debt Instrument [Line Items]
Net assets							680,000,000
Goodwill							283,000,000
Intangible assets							$ 195,900,000
OPKO Health Europe
Debt Instrument [Line Items]
Weighted average interest rate							1.50%		1.50%
Minimum | OPKO Health Europe
Debt Instrument [Line Items]
Variable interest rates							0.70%
Maximum | OPKO Health Europe
Debt Instrument [Line Items]
Variable interest rates							3.80%
Line of Credit
Debt Instrument [Line Items]
Remaining principal							$ 15,351,000		$ 13,672,000
Weighted average interest rate							5.40%		5.40%
Convertible Debt
Debt Instrument [Line Items]
Interest rate on notes payable			4.50%
Convertible Debt | Convertible Senior Notes Due 2025
Debt Instrument [Line Items]
Debt face amount			$ 200,000,000
Debt instrument, conversion ratio			0.2367424
Conversion price per share (in dollars per share) | $ / shares			$ 4.22
Converted debt amount		$ 55,400,000
Shares issued on converted debt (in shares) | shares		19,051,270					21,144,825		21,144,825
Loss on conversion of the 2025 Notes		$ 11,100,000
Shares issuable under debt agreement (in shares) | shares			30,000,000
Decrease in shares issuable under debt agreement (in shares) | shares		8,105,175
Proceeds one-time nominal fee							$ 300,000
Remaining principal							$ 141,537,000		$ 119,360,000
Convertible Debt | Convertible Senior Notes Due 2025 | Redemption period one
Debt Instrument [Line Items]
Convertible debt, threshold percentage of stock price trigger			130.00%
Equivalent redemption price (as a percent)			100.00%
Convertible Debt | Convertible Senior Notes Due 2025 | Redemption period one | Minimum
Debt Instrument [Line Items]
Number of trading days | day			20
Convertible Debt | Convertible Senior Notes Due 2025 | Redemption period one | Maximum
Debt Instrument [Line Items]
Number of consecutive trading days applicable conversion price | day			30
Convertible Debt | Convertible Senior Notes Due 2025 | Redemption period two
Debt Instrument [Line Items]
Convertible debt, threshold percentage of stock price trigger			98.00%
Convertible Debt | Convertible Senior Notes Due 2025 | Redemption period two | Minimum
Debt Instrument [Line Items]
Number of trading days | day			5
Convertible Debt | Convertible Senior Notes Due 2025 | Redemption period two | Maximum
Debt Instrument [Line Items]
Number of consecutive trading days applicable conversion price | day			5
Convertible Debt | Convertible Senior Notes Due 2025 | Redemption period three
Debt Instrument [Line Items]
Convertible debt, threshold percentage of stock price trigger							130.00%
Equivalent redemption price (as a percent)							100.00%
Convertible Debt | Convertible Senior Notes Due 2025 | Redemption period three | Minimum
Debt Instrument [Line Items]
Number of trading days | day							20
Convertible Debt | Convertible Senior Notes Due 2025 | Redemption period three | Maximum
Debt Instrument [Line Items]
Number of consecutive trading days applicable conversion price | day							30
Convertible Debt | 5% Convertible Notes
Debt Instrument [Line Items]
Debt face amount				$ 55,000,000
Interest rate on notes payable				5.00%
Conversion price per share (in dollars per share) | $ / shares				$ 5.00
Debt instrument, term				5 years
Minimum conversion notice				30 days
Maximum conversion notice				60 days
Remaining principal							$ 66,889,000		65,525,000
Convertible Debt | Notes Due February 1, 2033
Debt Instrument [Line Items]
Converted debt amount										$ 143,200,000
Senior Notes
Debt Instrument [Line Items]
Remaining principal							141,537,000		119,360,000
Senior Notes | Cumulative Effect, Period of Adoption, Adjustment | Accounting Standards Update 2020-06
Debt Instrument [Line Items]
Remaining principal									21,643,000
Senior Notes | Notes Due February 1, 2033
Debt Instrument [Line Items]
Debt face amount	$ 175,000,000
Interest rate on notes payable	3.00%
Equivalent redemption price (as a percent)	100.00%
Notes | Notes Due February 1, 2033
Debt Instrument [Line Items]
Equivalent redemption price (as a percent)						100.00%
Debt repurchase amount															$ 28,800,000
Remaining principal							3,050,000		3,050,000						$ 3,000,000
Revolving Credit Facility | Line of Credit | New Credit Agreement
Debt Instrument [Line Items]
Remaining principal							2,867,000		0
Credit line capacity					$ 75,000,000
Remaining borrowing capacity							53,100,000
Long-term line of credit, noncurrent							$ 2,900,000		$ 0
Revolving Credit Facility | Line of Credit | New Credit Agreement | 50% or more of revolving commitment
Debt Instrument [Line Items]
Commitment fee (as a percent)					0.375%
Revolving Credit Facility | Line of Credit | New Credit Agreement | Less than or equal to 50% of revolving commitment
Debt Instrument [Line Items]
Commitment fee (as a percent)					0.25%
Swingline | Line of Credit | New Credit Agreement
Debt Instrument [Line Items]
Credit line capacity					$ 20,000,000
Letter of Credit | Line of Credit | New Credit Agreement
Debt Instrument [Line Items]
Credit line capacity					$ 20,000,000
LIBOR | Revolving Credit Facility | Line of Credit | New Credit Agreement
Debt Instrument [Line Items]
Basis spread on variable rate					2.50%
LIBOR, First 12 Months | Revolving Credit Facility | Line of Credit | New Credit Agreement
Debt Instrument [Line Items]
Basis spread on variable rate					0.75%
LIBOR, First 12 Months, Adjusted for Eurocurrency Liabilities | Revolving Credit Facility | Line of Credit | New Credit Agreement
Debt Instrument [Line Items]
Basis spread on variable rate					1.75%
Common Stock | Convertible Debt | Notes Due February 1, 2033
Debt Instrument [Line Items]
Shares issued on converted debt (in shares) | shares										21,539,873

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Debt - Schedule of Notes (Details) - USD ($) $ in Thousands	6 Months Ended
	Jun. 30, 2022	Jun. 30, 2021
Debt Issuance Cost
Amortization of debt discount and debt issuance costs	$ 569	$ 424
Total
Beginning balance	205,272
Ending balance	232,449
Senior Notes
2025 Senior Notes
Beginning balance	144,580
Ending balance	144,580
Discount
Beginning balance	(22,747)
Amortization of debt discount and debt issuance costs	0
Ending balance	0
Debt Issuance Cost
Beginning balance	(2,473)
Amortization of debt discount and debt issuance costs	534
Ending balance	(3,043)
Total
Beginning balance	119,360
Amortization of debt discount and debt issuance costs	534
Ending balance	141,537
Senior Notes | Accounting Standards Update 2020-06 | Cumulative Effect, Period of Adoption, Adjustment
2025 Senior Notes
Beginning balance	0
Discount
Beginning balance	22,747
Debt Issuance Cost
Beginning balance	(1,104)
Total
Beginning balance	$ 21,643

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Debt - Lines of Credit (Details) - USD ($)	Jun. 30, 2022	Dec. 31, 2021
Line of Credit Facility [Line Items]
Credit line capacity	$ 104,844,000
Balance Outstanding	$ 18,218,000	$ 13,672,000
JPMorgan Chase
Line of Credit Facility [Line Items]
Interest rate on borrowings at June 30, 2022	3.25%
Credit line capacity	$ 75,000,000
Balance Outstanding	$ 2,867,000	0
Itau Bank
Line of Credit Facility [Line Items]
Interest rate on borrowings at June 30, 2022	5.50%
Credit line capacity	$ 1,900,000
Balance Outstanding	$ 1,293,000	1,603,000
Bank of Chile
Line of Credit Facility [Line Items]
Interest rate on borrowings at June 30, 2022	6.60%
Credit line capacity	$ 2,500,000
Balance Outstanding	$ 1,452,000	1,048,000
BICE Bank
Line of Credit Facility [Line Items]
Interest rate on borrowings at June 30, 2022	5.50%
Credit line capacity	$ 2,500,000
Balance Outstanding	$ 1,499,000	850,000
Scotiabank
Line of Credit Facility [Line Items]
Interest rate on borrowings at June 30, 2022	5.00%
Credit line capacity	$ 5,500,000
Balance Outstanding	$ 1,560,000	567,000
Santander Bank
Line of Credit Facility [Line Items]
Interest rate on borrowings at June 30, 2022	5.50%
Credit line capacity	$ 5,000,000
Balance Outstanding	$ 2,467,000	503,000
Security Bank
Line of Credit Facility [Line Items]
Interest rate on borrowings at June 30, 2022	5.50%
Credit line capacity	$ 1,400,000
Balance Outstanding	$ 2,000	1,111,000
Estado Bank
Line of Credit Facility [Line Items]
Interest rate on borrowings at June 30, 2022	5.50%
Credit line capacity	$ 4,000,000
Balance Outstanding	$ 2,682,000	2,540,000
BCI Bank
Line of Credit Facility [Line Items]
Interest rate on borrowings at June 30, 2022	5.00%
Credit line capacity	$ 2,500,000
Balance Outstanding	$ 2,400,000	2,515,000
Corpbanca
Line of Credit Facility [Line Items]
Interest rate on borrowings at June 30, 2022	5.00%
Credit line capacity	$ 0
Balance Outstanding	$ 0	2,935,000
International Bank
Line of Credit Facility [Line Items]
Interest rate on borrowings at June 30, 2022	5.50%
Credit line capacity	$ 1,500,000
Balance Outstanding	$ 845,000	0
Consoorcio Bank
Line of Credit Facility [Line Items]
Interest rate on borrowings at June 30, 2022	5.00%
Credit line capacity	$ 2,000,000
Balance Outstanding	$ 1,151,000	0
Banco De Sabadell
Line of Credit Facility [Line Items]
Interest rate on borrowings at June 30, 2022	1.75%
Credit line capacity	$ 522,000
Balance Outstanding	$ 0	0
Santander Bank
Line of Credit Facility [Line Items]
Interest rate on borrowings at June 30, 2022	2.15%
Credit line capacity	$ 522,000
Balance Outstanding	$ 0	$ 0

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Debt - Notes Payable and Other Debt (Details) - USD ($) $ in Thousands	Jun. 30, 2022	Dec. 31, 2021
Mortgage notes and other debt payables
Other long-term liabilities	$ 16,237	$ 15,062
Long-term debt	232,449	205,272
Notes Payable and Other Long-Term Liabilities
Mortgage notes and other debt payables
Current portion of notes payable	771	1,022
Other long-term liabilities	1,984	2,642
Long-term debt	$ 2,755	$ 3,664

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Accumulated Other Comprehensive Loss (Details) - USD ($) $ in Thousands	3 Months Ended		6 Months Ended
	Jun. 30, 2022	Jun. 30, 2021	Jun. 30, 2022	Jun. 30, 2021
Accumulated Other Comprehensive Income (Loss), Net [Rollforward]
Other comprehensive loss	$ (17,756)	$ 3,363	$ (18,676)	$ (5,707)
Foreign currency translation
Accumulated Other Comprehensive Income (Loss), Net [Rollforward]
Beginning balance			(30,495)
Other comprehensive loss			(18,676)
Ending balance	$ (49,171)		$ (49,171)

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Fair Value Measurements - Assets And Liabilities Measured At Fair Value (Details) - USD ($) $ in Thousands	Jun. 30, 2022	Dec. 31, 2021
Assets:
Money market funds	$ 131,658
Equity securities	1,508	$ 4,226
Equity Method - FV option	100,800	0
Total assets	234,411	4,364
Liabilities:
Contingent consideration	2,903	2,837
Total liabilities	2,903	2,837
Quoted prices in active markets for identical assets (Level 1)
Assets:
Money market funds	131,658
Equity securities	1,508	4,226
Equity Method - FV option	100,800
Total assets	233,966	4,226
Liabilities:
Contingent consideration	0	0
Total liabilities	0	0
Significant other observable inputs (Level 2)
Assets:
Money market funds	0
Equity securities	0	0
Equity Method - FV option	0
Total assets	445	138
Liabilities:
Contingent consideration	0	0
Total liabilities	0	0
Significant unobservable inputs (Level 3)
Assets:
Money market funds	0
Equity securities	0	0
Equity Method - FV option	0
Total assets	0	0
Liabilities:
Contingent consideration	2,903	2,837
Total liabilities	2,903	2,837
Common stock options/warrants
Assets:
Derivative assets	11	16
Common stock options/warrants | Quoted prices in active markets for identical assets (Level 1)
Assets:
Derivative assets	0	0
Common stock options/warrants | Significant other observable inputs (Level 2)
Assets:
Derivative assets	11	16
Common stock options/warrants | Significant unobservable inputs (Level 3)
Assets:
Derivative assets	0	0
Forward contracts
Assets:
Derivative assets	434	122
Forward contracts | Quoted prices in active markets for identical assets (Level 1)
Assets:
Derivative assets	0	0
Forward contracts | Significant other observable inputs (Level 2)
Assets:
Derivative assets	434	122
Forward contracts | Significant unobservable inputs (Level 3)
Assets:
Derivative assets	$ 0	$ 0

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Fair Value Measurements - Carrying Amount and Estimated Fair Value of Long-Term Debt (Details) - Notes $ in Thousands	Jun. 30, 2022 USD ($)
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Notes payable, fair value disclosure	$ 145,163
Level 1
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Notes payable, fair value disclosure	0
Level 2
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Notes payable, fair value disclosure	145,163
Level 3
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Notes payable, fair value disclosure	0
Carrying Value
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Notes payable, fair value disclosure	$ 141,537

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Fair Value Measurements - Level 3 Reconciliation (Details) - Contingent consideration $ in Thousands	6 Months Ended
	Jun. 30, 2022 USD ($)
Fair Value, Liabilities Measured on Recurring Basis, Unobservable Input Reconciliation, Calculation [Roll Forward]
Beginning Balance	$ 2,837
Change in fair value:
Included in results of operations	69
Foreign currency impact	(3)
Ending Balance	$ 2,903

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Fair Value Measurements - Narrative (Details) - USD ($) $ in Thousands	Jun. 30, 2022	Dec. 31, 2021
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Contingent consideration	$ 2,903	$ 2,837
Accrued Expenses
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Contingent consideration	500	500
LT notes payable included in long-term liabilities
Fair Value, Assets and Liabilities Measured on Recurring and Nonrecurring Basis [Line Items]
Contingent consideration	$ 2,400	$ 2,300

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Derivative Contracts - Balance Sheet Component (Details) - Not Designated as Hedging Instrument - USD ($) $ in Thousands	Jun. 30, 2022	Dec. 31, 2021
Common Stock options/warrants | Investments, net
Derivatives, Fair Value [Line Items]
Derivative asset	$ 11	$ 16
Forward contracts | Unrealized gains on forward contracts are recorded in Other current assets and prepaid expenses. Unrealized (losses) on forward contracts are recorded in Accrued expenses.
Derivatives, Fair Value [Line Items]
Derivative asset	$ 434	$ 122

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Derivative Contracts - Derivative Gains (Losses) (Details) - Not Designated as Hedging Instrument - USD ($) $ in Thousands	3 Months Ended		6 Months Ended
	Jun. 30, 2022	Jun. 30, 2021	Jun. 30, 2022	Jun. 30, 2021
Derivative Instruments, Gain (Loss) [Line Items]
Derivative gain (loss)	$ 338	$ (272)	$ 206	$ (711)
Common Stock options/warrants
Derivative Instruments, Gain (Loss) [Line Items]
Derivative gain (loss)	(4)	(26)	(5)	(6)
Forward contracts
Derivative Instruments, Gain (Loss) [Line Items]
Derivative gain (loss)	$ 342	$ (246)	$ 211	$ (705)

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Related Party Transactions (Details)	1 Months Ended	3 Months Ended		6 Months Ended
	Aug. 31, 2020 USD ($)	Jun. 30, 2022 USD ($) shares	Jun. 30, 2021 USD ($)	Jun. 30, 2022 USD ($) shares	Jun. 30, 2021 USD ($)	Aug. 01, 2019 USD ($) ft²
Related Party Transaction [Line Items]
Related party expenses		$ 0	$ 0	$ 30,000	$ 43,000
Detect Genomix | Variable Interest Entity, Not Primary Beneficiary
Related Party Transaction [Line Items]
Additional investment in equity method investment	$ 245,000
Equity method investments (as a percent)	49.00%
Pharmsynthez
Related Party Transaction [Line Items]
Equity method investments (as a percent)		9.00%		9.00%
Zebra
Related Party Transaction [Line Items]
Stock ownership (as a percent)				29.00%
Zebra | Variable Interest Entity, Not Primary Beneficiary
Related Party Transaction [Line Items]
Equity method investments (as a percent)		29.00%		29.00%
Neovasc
Related Party Transaction [Line Items]
Equity method investments (as a percent)		1.00%		1.00%
ChromaDex Corporation
Related Party Transaction [Line Items]
Equity security investments (as a percent)		0.10%		0.10%
COCP
Related Party Transaction [Line Items]
Equity method investments (as a percent)		3.00%		3.00%
NIMS
Related Party Transaction [Line Items]
Equity security investments (as a percent)		1.00%		1.00%
Eloxx Pharmaceuticals
Related Party Transaction [Line Items]
Equity security investments (as a percent)		1.00%		1.00%
BioCardia, Inc.
Related Party Transaction [Line Items]
Equity method investments (as a percent)		1.00%		1.00%
Equity security investments (as a percent)		1.00%		1.00%
LeaderMed
Related Party Transaction [Line Items]
Stock ownership (as a percent)				47.00%
InCellDx, Inc
Related Party Transaction [Line Items]
Equity method investments (as a percent)		29.00%		29.00%
Detect Genomix
Related Party Transaction [Line Items]
Related party expenses				$ 335,300
Due from affiliate		$ 167,200		167,200
Frost Real Estate Holdings LLC
Related Party Transaction [Line Items]
Area of real estate property (in square feet) | ft²						29,500
Lease payments per month in first year						$ 89,000
Lease payments per month in fifth year						$ 101,000
Beckman Coulter
Related Party Transaction [Line Items]
Related party expenses				1,700,000
Integrated DNA Technologies Inc.
Related Party Transaction [Line Items]
Related party expenses				100,000
Leica Microsystems Inc.
Related Party Transaction [Line Items]
Related party expenses				$ 300,000
Shares Received Upon Closing of Xenetic Transaction | Director
Related Party Transaction [Line Items]
Shares received upon closing of transaction (in shares) | shares		31,240		31,240
Mednax Services, Inc. | Detect Genomix | Variable Interest Entity, Not Primary Beneficiary
Related Party Transaction [Line Items]
Additional investment in equity method investment	$ 255,000
Equity method investments (as a percent)	51.00%

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Commitments and Contingencies (Details) - USD ($) $ in Thousands		1 Months Ended	6 Months Ended
	Sep. 22, 2020	Jan. 31, 2021	Jun. 30, 2022	Dec. 31, 2021	Apr. 05, 2019
Business Acquisition, Contingent Consideration
Contingent consideration			$ 2,903	$ 2,837
Inventory received but not invoiced			197,200
Settled Litigation | Civil Investigative Demands
Business Acquisition, Contingent Consideration
Litigation settlement amount			10,000
Current litigation liability			10,500	10,000
Settled Litigation | Chancery Court of Delaware vs Company
Business Acquisition, Contingent Consideration
Litigation settlement amount		$ 1,200
Milestone payment					$ 2,375
Settled Litigation | Southern District of New York vs BioReference
Business Acquisition, Contingent Consideration
Litigation settlement amount	$ 11,500
Accrued Liabilities
Business Acquisition, Contingent Consideration
Contingent consideration			500	500
LT notes payable included in long-term liabilities
Business Acquisition, Contingent Consideration
Contingent consideration			$ 2,400	$ 2,300

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Revenue Recognition - Narrative (Details) - USD ($) $ in Thousands		1 Months Ended	3 Months Ended		6 Months Ended		90 Months Ended
	May 05, 2020	Jan. 31, 2015	Jun. 30, 2022	Jun. 30, 2021	Jun. 30, 2022	Jun. 30, 2021	Jun. 30, 2022	Dec. 31, 2021
Disaggregation of Revenue [Line Items]
Prior period performance obligation revenue recognized					$ 21,200	$ 28,500
Overpayment reimbursement liability			$ 1,500		1,500		$ 1,500	$ 5,000
Revenue recognized					17
Total revenues			309,893	$ 442,408	639,111	987,573
Rayaldee
Disaggregation of Revenue [Line Items]
Revenue recognized			6,200	5,000	11,300	10,800
Total revenues			15,382	16,122	28,861	31,767
Transfer of intellectual property and other
Disaggregation of Revenue [Line Items]
Total revenues			87,197	9,548	93,159	13,816
Products | Transfer of intellectual property and other
Disaggregation of Revenue [Line Items]
Total revenues	$ 3,000
Pfizer | Products
Disaggregation of Revenue [Line Items]
Revenue recognized							$ 85,000
Maximum milestone payments		$ 275,000
Initial upfront payment		$ 295,000
Pfizer | Products | Transfer of intellectual property and other
Disaggregation of Revenue [Line Items]
Total revenues			$ 2,300	$ 2,800	4,500	$ 5,600
Maximum milestone payments					85,000
VFMCRP | Products | Transfer of intellectual property and other
Disaggregation of Revenue [Line Items]
Total revenues					3,000
Nicoya
Disaggregation of Revenue [Line Items]
Initial upfront payment					$ 5,000

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Revenue Recognition - Schedule of Disaggregation of Revenue (Details) - USD ($) $ in Thousands	3 Months Ended		6 Months Ended
	Jun. 30, 2022	Jun. 30, 2021	Jun. 30, 2022	Jun. 30, 2021
Disaggregation of Revenue [Line Items]
Total revenues	$ 309,893	$ 442,408	$ 639,111	$ 987,573
Services
Disaggregation of Revenue [Line Items]
Total revenues	186,804	397,197	473,402	904,149
Healthcare insurers
Disaggregation of Revenue [Line Items]
Total revenues	76,442	109,084	172,269	273,913
Government payers
Disaggregation of Revenue [Line Items]
Total revenues	25,659	57,611	53,263	131,269
Client payers
Disaggregation of Revenue [Line Items]
Total revenues	80,931	225,936	240,021	488,845
Patients
Disaggregation of Revenue [Line Items]
Total revenues	$ 3,772	$ 4,566	$ 7,849	$ 10,122

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Revenue Recognition - Schedule of Product Sales Allowances and Accruals (Details) - USD ($) $ in Thousands	3 Months Ended		6 Months Ended		12 Months Ended
	Jun. 30, 2022	Jun. 30, 2021	Jun. 30, 2022	Jun. 30, 2021	Dec. 31, 2021
Accounts Receivable, Allowance for Credit Loss [Roll Forward]
Provision related to current period sales	$ 100	$ 300	$ 200	$ 600
Total revenues	309,893	442,408	639,111	987,573
Rayaldee
Accounts Receivable, Allowance for Credit Loss [Roll Forward]
Beginning balance	9,203	11,389	10,152	11,737	$ 11,737
Provision related to current period sales	9,161	11,107	17,514	20,929
Credits or payments made	(8,588)	(9,885)	(17,890)	(20,055)
Ending balance	9,776	12,611	9,776	12,611	10,152
Total revenues	$ 15,382	$ 16,122	$ 28,861	$ 31,767
Provision for Rayaldee sales allowances and accruals as a percentage of gross Rayaldee sales	60.00%	69.00%	61.00%	66.00%
Chargebacks, discounts, rebates and fees | Rayaldee
Accounts Receivable, Allowance for Credit Loss [Roll Forward]
Beginning balance	$ 1,588	$ 1,693	$ 2,014	$ 2,332	2,332
Provision related to current period sales	3,411	3,724	6,626	7,539
Credits or payments made	(3,330)	(3,716)	(6,971)	(8,170)
Ending balance	1,669	1,701	1,669	1,701	2,014
Governmental | Rayaldee
Accounts Receivable, Allowance for Credit Loss [Roll Forward]
Beginning balance	5,282	6,209	5,499	5,812	5,812
Provision related to current period sales	5,442	7,061	10,311	12,755
Credits or payments made	(4,235)	(5,684)	(9,321)	(10,981)
Ending balance	6,489	7,586	6,489	7,586	5,499
Returns | Rayaldee
Accounts Receivable, Allowance for Credit Loss [Roll Forward]
Beginning balance	2,333	3,487	2,639	3,593	3,593
Provision related to current period sales	308	322	577	635
Credits or payments made	(1,023)	(485)	(1,598)	(904)
Ending balance	$ 1,618	$ 3,324	$ 1,618	$ 3,324	$ 2,639

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Revenue Recognition - Changes in Contractual Liabilities Balance (Details) $ in Thousands	6 Months Ended
	Jun. 30, 2022 USD ($)
Contract with Customer, Liability [Abstract]
Beginning balance	$ 466
Revenue recognized	17
Ending balance	$ 449

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Strategic Alliances (Details) - USD ($) $ in Thousands						1 Months Ended		3 Months Ended		6 Months Ended		12 Months Ended	90 Months Ended
	Sep. 14, 2021	Jul. 06, 2021	Jun. 18, 2021	May 05, 2020	Oct. 21, 2019	May 31, 2016	Jan. 31, 2015	Jun. 30, 2022	Jun. 30, 2021	Jun. 30, 2022	Jun. 30, 2021	Dec. 31, 2021	Jun. 30, 2022
Collaborative Arrangement and Arrangement Other than Collaborative [Line Items]
Total revenues								$ 309,893	$ 442,408	$ 639,111	$ 987,573
Milestone revenue recognized										17
LeaderMed | LeaderMed Joint Venture | Corporate Joint Venture
Collaborative Arrangement and Arrangement Other than Collaborative [Line Items]
Ownership interest in joint venture (as a percent)	47.00%
Initial investment in joint venture	$ 11,000
Ownership percentage by related parties (as a percent)	53.00%
CAMP4
Collaborative Arrangement and Arrangement Other than Collaborative [Line Items]
Upfront payment (in shares)		3,373,008
Outstanding shares (as a percent)		9.00%
Period following first commercial sale in a country		10 years
Nicoya
Collaborative Arrangement and Arrangement Other than Collaborative [Line Items]
Upfront payment from development and license agreement			$ 5,000
Period after first commercial sale			10 years
Initial upfront payment										5,000
Pfizer | Products
Collaborative Arrangement and Arrangement Other than Collaborative [Line Items]
Maximum milestone payments							$ 275,000
Milestone payments								85,000
Annual height velocity at point in time					12 months
Initial upfront payment							295,000
Additional milestone payment							275,000
Milestone revenue recognized													$ 85,000
Minimum | Pfizer | Products
Collaborative Arrangement and Arrangement Other than Collaborative [Line Items]
Milestone payments							20,000
Maximum | Pfizer | Products
Collaborative Arrangement and Arrangement Other than Collaborative [Line Items]
Milestone payments							$ 90,000
Phase Three Initiation | Nicoya
Collaborative Arrangement and Arrangement Other than Collaborative [Line Items]
Upfront payment from development and license agreement			$ 5,000
Regulatory and Development | Nicoya
Collaborative Arrangement and Arrangement Other than Collaborative [Line Items]
Milestone payment from development and license agreement			$ 115,000
Transfer of intellectual property and other
Collaborative Arrangement and Arrangement Other than Collaborative [Line Items]
Total revenues								87,197	9,548	93,159	13,816
Transfer of intellectual property and other | Products
Collaborative Arrangement and Arrangement Other than Collaborative [Line Items]
Total revenues				$ 3,000
Transfer of intellectual property and other | LeaderMed | LeaderMed Joint Venture | Corporate Joint Venture
Collaborative Arrangement and Arrangement Other than Collaborative [Line Items]
Total revenues	$ 1,000											$ 1,000
Transfer of intellectual property and other | CAMP4
Collaborative Arrangement and Arrangement Other than Collaborative [Line Items]
Total revenues		$ 1,500
Transfer of intellectual property and other | VFMCRP | Products
Collaborative Arrangement and Arrangement Other than Collaborative [Line Items]
Total revenues										3,000
Transfer of intellectual property and other | Pfizer | Products
Collaborative Arrangement and Arrangement Other than Collaborative [Line Items]
Total revenues								2,300	2,800	4,500	5,600
Maximum milestone payments										85,000
Dravet Syndrome Products | CAMP4
Collaborative Arrangement and Arrangement Other than Collaborative [Line Items]
Development milestone payments		3,500
Sales milestone payments		$ 90,000
Development milestone payments (in shares)		5,782,299
Non-Dravet Syndrome Products | CAMP4
Collaborative Arrangement and Arrangement Other than Collaborative [Line Items]
Development milestone payments		$ 4,000
Sales milestone payments		$ 90,000
Development milestone payments (in shares)		1,082,248
Products
Collaborative Arrangement and Arrangement Other than Collaborative [Line Items]
Total revenues								$ 35,892	$ 35,663	$ 72,550	$ 69,608
Regulatory Milestones | EirGen Pharma Limited
Collaborative Arrangement and Arrangement Other than Collaborative [Line Items]
Maximum milestone payments				17,000
Sales Milestones | EirGen Pharma Limited
Collaborative Arrangement and Arrangement Other than Collaborative [Line Items]
Maximum milestone payments				$ 207,000
Exclusive Option | VFMCRP
Collaborative Arrangement and Arrangement Other than Collaborative [Line Items]
Maximum milestone payments						$ 555,000

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Segments - Narrative (Details)	6 Months Ended
	Jun. 30, 2022 USD ($) segment
Segment Reporting Information [Line Items]
Number of reportable segments | segment	2
Intersegment Elimination
Segment Reporting Information [Line Items]
Inter-segment sales	$ 0
Inter-segment allocation of interest expense	$ 0

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Segments - Operations and Assets Information (Details) - USD ($) $ in Thousands	3 Months Ended		6 Months Ended
	Jun. 30, 2022	Jun. 30, 2021	Jun. 30, 2022	Jun. 30, 2021	Jan. 01, 2022	Dec. 31, 2021
Segment Reporting Information [Line Items]
Total revenues	$ 309,893	$ 442,408	$ 639,111	$ 987,573
Operating income (loss)	(10,739)	5,571	(83,164)	44,008
Depreciation and amortization	27,995	20,573	55,809	40,561
Loss from investment in investees	(268)	(67)	(316)	(110)
Assets	2,369,602		2,369,602			$ 2,399,715
Goodwill	578,845		578,845		$ 710,408	520,601
United States
Segment Reporting Information [Line Items]
Total revenues	193,105	402,291	484,913	915,163
Ireland
Segment Reporting Information [Line Items]
Total revenues	89,177	12,088	97,638	19,218
Chile
Segment Reporting Information [Line Items]
Total revenues	15,804	18,657	32,143	32,809
Spain
Segment Reporting Information [Line Items]
Total revenues	5,696	5,437	12,805	11,356
Israel
Segment Reporting Information [Line Items]
Total revenues	1,854	724	3,412	3,235
Mexico
Segment Reporting Information [Line Items]
Total revenues	4,055	3,039	7,805	5,457
Other
Segment Reporting Information [Line Items]
Total revenues	202	172	395	335
Corporate
Segment Reporting Information [Line Items]
Operating income (loss)	(8,631)	(10,719)	(19,399)	(20,138)
Depreciation and amortization	0	0	0	0
Loss from investment in investees	0	0	0	0
Assets	267,379		267,379			46,672
Pharmaceutical | Operating Segments
Segment Reporting Information [Line Items]
Operating income (loss)	55,435	(13,710)	37,327	(32,868)
Depreciation and amortization	17,840	7,007	33,242	14,420
Loss from investment in investees	(268)	(67)	(316)	(110)
Assets	1,354,058		1,354,058			1,114,460
Goodwill	295,820		295,820			237,576
Diagnostics | Operating Segments
Segment Reporting Information [Line Items]
Operating income (loss)	(57,543)	30,000	(101,092)	97,014
Depreciation and amortization	10,155	13,566	22,567	26,141
Loss from investment in investees	0	0	0	0
Assets	748,165		748,165			1,238,583
Goodwill	283,025		283,025			$ 283,025
Services
Segment Reporting Information [Line Items]
Total revenues	186,804	397,197	473,402	904,149
Services | Corporate
Segment Reporting Information [Line Items]
Total revenues	0	0	0	0
Services | Pharmaceutical | Operating Segments
Segment Reporting Information [Line Items]
Total revenues	0	0	0	0
Services | Diagnostics | Operating Segments
Segment Reporting Information [Line Items]
Total revenues	186,804	397,197	473,402	904,149
Products
Segment Reporting Information [Line Items]
Total revenues	35,892	35,663	72,550	69,608
Products | Corporate
Segment Reporting Information [Line Items]
Total revenues	0	0	0	0
Products | Pharmaceutical | Operating Segments
Segment Reporting Information [Line Items]
Total revenues	35,892	35,663	72,550	69,608
Products | Diagnostics | Operating Segments
Segment Reporting Information [Line Items]
Total revenues	0	0	0	0
Transfer of intellectual property and other
Segment Reporting Information [Line Items]
Total revenues	87,197	9,548	93,159	13,816
Transfer of intellectual property and other | Corporate
Segment Reporting Information [Line Items]
Total revenues	0	0	0	0
Transfer of intellectual property and other | Pharmaceutical | Operating Segments
Segment Reporting Information [Line Items]
Total revenues	87,197	9,548	93,159	13,816
Transfer of intellectual property and other | Diagnostics | Operating Segments
Segment Reporting Information [Line Items]
Total revenues	$ 0	$ 0	$ 0	$ 0

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Leases - Lease Assets and Liabilities (Details) - USD ($) $ in Thousands	Jun. 30, 2022	Dec. 31, 2021
Assets
Operating lease assets	$ 42,412	$ 44,228
Finance lease assets	$ 7,213	5,181
Finance Lease, Right-of-Use Asset, Statement of Financial Position [Extensible List]	Property, Plant, and Equipment and Finance Lease Right-of-Use Asset, after Accumulated Depreciation and Amortization
Current
Operating lease liabilities	$ 12,122	11,624
Accrued expenses	2,625	2,257
Long-term
Operating lease liabilities	30,876	33,097
Other long-term liabilities	$ 4,588	$ 2,924
Weighted average remaining lease term
Operating leases	6 years 4 months 24 days	7 years 2 months 12 days
Finance leases	3 years 2 months 12 days	2 years 4 months 24 days
Weighted average discount rate
Operating leases	3.70%	4.60%
Finance leases	7.00%	4.80%

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Leases - Lease Liability Maturity (Details) $ in Thousands	Jun. 30, 2022 USD ($)
Operating
July 1, 2022 through December 31, 2022	$ 6,322
2023	10,399
2024	7,025
2025	4,541
2026	3,654
Thereafter	15,493
Total undiscounted future minimum lease payments	47,434
Less: Difference between lease payments and discounted lease liabilities	4,436
Total lease liabilities	42,998
Finance
July 1, 2022 through December 31, 2022	1,528
2023	2,430
2024	1,829
2025	1,291
2026	636
Thereafter	2
Total undiscounted future minimum lease payments	7,716
Less: Difference between lease payments and discounted lease liabilities	503
Total lease liabilities	$ 7,213

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Leases - Narrative (Details) - USD ($) $ in Millions	6 Months Ended
	Jun. 30, 2022	Jun. 30, 2021
Leases [Abstract]
Operating lease expense	$ 8.4	$ 9.1
Finance lease expense	1.9	1.1
Variable lease expense	$ 1.3	$ 1.4

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Leases - Lease Cash Flow Information (Details) - USD ($) $ in Thousands	6 Months Ended
	Jun. 30, 2022	Jun. 30, 2021
Leases [Abstract]
Operating cash out flows from operating leases	$ 8,327	$ 6,484
Operating cash out flows from finance leases	52	45
Financing cash out flows from finance leases	724	769
Total	$ 9,103	$ 7,298

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Subsequent Events (Details) - Subsequent Event	Jul. 14, 2022 USD ($)
Subsequent Event [Line Items]
Litigation settlement, corporate integrity agreement, term	5 years
Settled Litigation
Subsequent Event [Line Items]
Litigation settlement amount	$ 10,000,000
Litigation settlement, interest rate	1.50%
UNITED STATES | Settled Litigation
Subsequent Event [Line Items]
Litigation settlement amount	$ 9,853,958
MASSACHUSETTS | Settled Litigation
Subsequent Event [Line Items]
Litigation settlement amount	141,041
CONNECTICUT | Settled Litigation
Subsequent Event [Line Items]
Litigation settlement amount	$ 5,001