Hello, and welcome to the BioMarin Pharmaceutical Third Quarter 2025 Conference Call. [Operator Instructions]. I would now like to turn the conference over to Traci McCarty. Please go ahead.

Thank you, operator. To remind you, this nonconfidential presentation contains forward-looking statements about the business prospects of BioMarin Pharmaceutical Inc., including expectations regarding BioMarin's financial performance, commercial products and potential future products in different areas of therapeutic research and development. Results may differ materially depending on the progress of BioMarin's product programs, actions of regulatory authorities, availability of capital, future actions in the pharmaceutical market and developments by competitors and those factors detailed in BioMarin's filings with the Securities and Exchange Commission, such as 10-Q, 10-K and 8-K reports. In addition, we will use non-GAAP financial metrics as defined in Regulation G during the call today. These non-GAAP measures should not be considered in isolation from, as substitutes for or superior to financial measures prepared in accordance with U.S. GAAP, and you can find the related reconciliations to U.S. GAAP in the earnings release and earnings presentation, both of which are available in the Investor Relations section of our website. Please note that our commentary on today's call will focus on non-GAAP financial measures unless otherwise indicated. Beginning on Slide 3 and introducing BioMarin's management team, joining today's call, Alexander Hardy, President and Chief Executive Officer; Brian Mueller, Chief Financial Officer; Cristin Hubbard, Chief Commercial Officer; and Greg Friberg, Chief R&D Officer. I will now turn the call over to BioMarin's President and CEO, Alexander Hardy.

Thank you, Traci. Good afternoon, everyone, and thank you for joining us on today's call. Starting on Slide 5, I am very pleased with the strong results across the business, leading us to raise full year total revenues guidance at the midpoint and reaffirm our VOXZOGO revenue outlook for 2025. In addition to top line performance, BioMarin has delivered expanding profitability and significant growth in operating cash flow, bringing our cash and investments balance to approximately $2 billion at the end of the third quarter. We are focused on finishing the year strong, positioning ourselves to achieve record commercial results for the full year. To date this year, we have delivered 11% increase in top line growth year-over-year. These strong results are driven by the performance of our global enzyme therapies and Skeletal Conditions business units as we deliver for patients around the world. We have built the Enzyme Therapies business unit into a $2 billion-plus franchise over the last 12 months with continued growth anticipated. In the Skeletal Conditions business unit, our first indication with our first product, VOXZOGO, the treatment of achondroplasia is expected to generate more than $900 million in revenues this year, leading us to reaffirm our full year 2025 VOXZOGO outlook and representing 25% growth at the midpoint of our guidance range. As the established standard of care in achondroplasia, VOXZOGO revenue has increased 24% year-to-date compared to 2024. Now in the fourth year of its global launch, VOXZOGO has represented a breakthrough therapy for families seeking treatment for their children with achondroplasia. Building on this innovation, we are excited to bring VOXZOGO's second indication forward for the treatment of children with hypochondroplasia. We have high confidence in the upcoming pivotal data readout for hypochondroplasia expected in the first half of next year based on…

Thank you, Alexander. Please refer to today's press release for detailed third quarter 2025 results, including reconciliations of GAAP to non-GAAP financial measures. All 2025 results will be available in our upcoming Form 10-Q, which we expect to file in the coming days. Starting on Slide 7. Strong global demand across our portfolio of innovative medicines drove a year-to-date total revenue increase of 11% compared to the same period in 2024. Revenues from VOXZOGO and PALYNZIQ each increased by more than 20% on a year-to-date basis. As we shared last quarter, we anticipate VOXZOGO revenue in Q4 to reach its highest level of the year due to the timing of contracted orders as well as increasing numbers of patients on therapy, and we expect full year 2025 VOXZOGO revenue of between $900 million and $935 million. We are pleased with 8% year-to-date growth of the Enzyme Therapies business unit led by PALYNZIQ. Due to large orders for NAGLAZYME and VIMIZIM in the second quarter, we note that Enzyme Therapies revenue was lower in Q3 quarter-over-quarter. And compared to Q3 2024, Enzyme Therapy revenue in the quarter was relatively flat, primarily due to a higher volume ALDURAZYME quarter last year. Given the strong top line performance so far this year and our expectations for the fourth quarter, we are raising the lower end of our full year 2025 total revenue guidance to $3.15 billion, with the midpoint of the range representing double-digit year-over-year growth. Now moving to Slide 8. Q3 2025 results include a charge of $221 million for acquired in-process research and development, or IPR&D, on a pretax basis related to the Inozyme Pharma acquisition completed on July 1 of this year. This acquisition-related expense represents an approximate impact of $1.10 on a per share basis. The IPR&D charges significantly…

Thank you, Brian. I want to begin by acknowledging the exceptional work from our teams across the world, whose dedication has delivered strong year-to-date results for BioMarin's commercial portfolio. Now moving to Slide 11. We are pleased that PALYNZIQ'S strong performance resulted in another quarter of more than 20% growth, reflecting more patients reaching efficacy and adhering to therapy. PALYNZIQ'S sustained growth demonstrates the PKU community's continued belief in its unparalleled efficacy profile and the importance of reaching normal Phe levels for effective treatment. We are pursuing approval of PALYNZIQ for adolescents aged 12 to 17 in the United States and Europe in 2026, potentially enabling this younger group of people to have access to therapy during an important period of transition to adulthood. Beyond PALYNZIQ, year-to-date revenue growth across our enzyme therapies portfolio reflects increased new patient starts across all products and strong adherence to therapy, reinforcing the durability and high penetration of these treatments despite quarter-to-quarter order timing dynamics. Now moving to Slide 12. VOXZOGO for the treatment of achondroplasia was available in 55 countries as of the end of the third quarter with new launches across multiple geographies. Global expansion and demand drove year-over-year VOXZOGO revenue growth of 15% in the third quarter and 24% year-to-date with growth in patient numbers quarter-over-quarter. For the remainder of 2025, we expect large contracted OUS orders, deeper penetration across our growing VOXZOGO footprint and quarter-to-quarter new patient starts to result in Q4 being the highest of VOXZOGO revenue for the year. Outside the U.S., with a large majority of children eligible for VOXZOGO located, our global footprint remains a powerful growth engine, and we saw strong uptake across key large markets during the quarter. With approximately 75% of year-to-date VOXZOGO revenue generated outside the U.S., we expect significant opportunity ahead…

Thank you, Cristin. Now moving to Slide 16 and to provide a little more color, hypochondroplasia is a serious condition with a potentially broad impact on the health and daily life of those affected. Children and adults with hypochondroplasia can face significantly higher rates of comorbidities and procedures when compared to the general population, covering areas like respiratory, orthopedic, ear nose and throat and mental health. As a result, they often undergo more surgeries, adding to the overall burden of the condition. Beyond the medical challenges, the condition can affect quality of life in very real ways, making everyday tasks harder and creating social and emotional strain. These insights reinforce why it's important to advance treatment options for hypochondroplasia, a condition for which no approved therapies are broadly available today. Now moving to Slide 17. At ASBMR in September, we presented important spinal morphology data for children under 5 years old with achondroplasia. These children were treated on our Phase II CANOPY study with either vosoritide or placebo. Spinal morphology is one of the factors that contributes to spinal stenosis, a leading cause of morbidity in achondroplasia. Spinal stenosis, particularly in the lumbar region, is a serious and all too common medical complication in achondroplasia, resulting in pain, muscle weakness and reduced mobility in the most severe cases. Since measures of spinal canal reach near final size by age 5, early intervention is essential to prevent complications. Radiographs of the spine in our CANOPY study demonstrated that children who received VOXZOGO experienced improved spinal measurements across all lumbar vertebrae and an overall improved curvature of the spine after just 1 year of treatment. As a reminder, these improvements were seen as compared to placebo rather than simply describing the natural history of growing children. As these anatomic measures are often…

[Operator Instructions]. Your first question comes from Phil Nadeau with TD Cowen.

My question is on the 2027 guidance. Can you talk a little bit more about the scenarios you see? And maybe more specifically, why are you rescinding the guidance now? What has changed over the last year since it was initially issued?

Phil, this is Brian. Thanks for the question. I'll take that one. Since we shared the original $4 billion 2027 outlook last year, we've had a year to assess the various factors that have arisen since then, including the impact of potential VOXZOGO competition. There's other puts and takes. We've got our acquisition of Inozyme and the potential for BMN 401 to launch in the pediatric indication in '27. We've also incorporated today's announcement that we're pursuing options to divest ROCTAVIAN. We've developed a number of scenarios to capture what we believe are different outcomes across these key variables across the entire portfolio. But given the many unknowns and their impact on predicting 2027 revenue, instead of taking an official position on those key assumptions, what we've done is outline the range of our lower case estimates and our higher case estimates. I'll share that in the lower case estimate, that reflects the scenario with 2 competitors successfully launching and taking significant share by 2027. And I'll share in the high case, that reflects the scenario where there's a significant delay in the competition, for example, successful intellectual property events for BioMarin. And again, in between there, there are a number of outcomes, highly uncertain at this time and therefore, narrowing the range or coming up with more specific point-in-time estimates at this time isn't appropriate. Again, I'll just finish by saying, reiterating my comments in the prepared remarks that in that lower case estimate for BioMarin, we are still at consensus for 2027.

And maybe just a follow-up. I think when you issued the guidance a year ago, you were -- you suggested that competition was factored into the guidance. Do you now have a different appreciation or a different concern about how much share that competition could take, specifically against VOXZOGO?

Yes. Thanks, Phil. We did the initial work last year following Investor Day when the competitor data was released and at the time, modeled some competitive impact. There was some ability to absorb that into our original forecast at the time, and we did have some other upsides last year. We have taken a different view. We've observed trends in the marketplace, both what we are experiencing in these markets as well as, again, different potential competitor scenarios. And this is not a single point in time estimate. It is not our forecast. We merely wanted to reflect what the range of outcomes could be from our view.

The next question comes from Salveen Richter with Goldman Sachs.

Could you speak to why VOXZOGO sales were down quarter-over-quarter? And then also just help us understand here the business development strategy, just given that there seems to be so much of a focus on VOXZOGO and how that plays out, but you're kind of stuck from just given all these various dynamics competitively, when can we start to see that business development lever or levers kind of emerge to really add to your portfolio?

Salveen, this is Brian. I'll take the first part of the question on Q3, VOXZOGO. And yes, slightly down quarter-over-quarter. Looking back to the remarks that we made back last quarter when we signaled that we were expecting VOXZOGO revenue for the second half of the year to be back weighted to the fourth quarter. We noted a couple of specific larger orders where there were true timing shifts, but also just our market-by-market forecast for Q3 and Q4, what ended up happening in Q3 is that, that was just a bit more exacerbated and the timing shifted a little more. I'll point you to 2 things. One, reaffirming the total VOXZOGO range today for the year of $900 million to $935 million, again, just timing between Q3 and Q4. And then secondly and most importantly, steadily adding patients across all markets and all age groups in Q3, which, again, just -- that's the key indicator of long-term demand, and we're going to continue to experience some of these quarter-to-quarter order timing fluctuations.

Salveen, thanks very much for your question. It's Alexander. I'll answer the part of your question around business development. First off, I would say we've got strong underlying business performance in both Enzyme Therapies and in Skeletal Conditions. I mean, 11% year-to-date growth across both business units. But we are also producing significant cash flow. Our balance sheet is very strong, and we have conviction that assets are worth more in our hands than they are right now. So business development is a very important part of our strategy right now. We have a number of deals that we're in pursuit of. We've always been a company focused on early-stage collaborations. But what is different or how our strategy has evolved is we're also looking at Phase III pre-commercial and commercial assets because, again, we think we can add value to all stakeholders with those in our hands. So we have a number of deals in the works and in sight. I mean, obviously, business development is never completely within your control, but it remains a very high priority for us, and we're looking forward to sharing more information when we have that.

The next question comes from Cory Kasimov with Evercore.

I guess I have a follow-up on 2 questions that were asked. First of all, Brian, I appreciate the commentary you made on the previously issued '27 guidance. I think the way you framed it is helpful. However, I'm curious if you have any qualitative commentary you could also share on your prior long-term mid-2030s guidance with regard both to the opportunity for VOXZOGO as well as the anticipated CAGR for the Enzyme Therapies business. And then a follow-up for Alexander's capital deployment commentary. Given the pretty big cash balance and good operating cash flow generation you alluded to, have you given much consideration to share buybacks? Or are you really just holding that capital for other uses like BD as you were talking about?

Thanks, Cory. This is Brian. Appreciate the question. And it's a similar analysis, as I shared with the 27 range of estimates there. We are absolutely planning on continued sustainable growth across the business. I'll share that we are still targeting high single-digit sustainable growth rate for the enzyme therapies over time. VOXZOGO, we do plan to continue to grow the brand by deepening patient penetration across all markets, plus the indication expansion opportunities where we will always have a lead. However, the offsets to that, most notably being potential competition are still very uncertain at this time. So we and the investor community will watch all of these variables very closely, and we'll keep you updated in terms of what we're seeing along the way. But again, we feel it's prudent to avoid taking an official position on a forecast with so many uncertainties. So not quoting a long-term growth rate at this time for that reason.

Cory, this is Alexander. I'll answer the second part of your question with regard to capital allocation. It's obviously something we discuss with our Board frequently. It's very, very important, obviously, that we're really effective stewards of the significant capital that we've generated through the success of our business. We actually think that business development is the greatest opportunity for us to drive significant incremental growth rate on the top line, and that's the most highly correlated with stock appreciation. We have this strong financial profile. We have this capability in rare diseases, whether it's in research, development, manufacturing, commercialization. And we're convicted that assets are worth more in our hands than where they are right now. In an environment that we have right now in the U.S. with biotech stocks, there are many rare disease companies that are undercapitalized and underresourced and those assets are worth more in our hands. So we are -- as you can tell, we're very convicted that business development is the best use of our capital. That remains our priority, but it's something that as a Board, we constantly look at.

The next question comes from Joe Schwartz with Leerink Partners.

For the upcoming BMN 333 PK data, what specific exposure levels would give you confidence that you can achieve clinical superiority over VOXZOGO? And as you move into a head-to-head superiority trial against VOXZOGO, what is the minimum annualized growth velocity delta over VOXZOGO that you believe could be required to demonstrate clear clinical superiority, drive patient switching and reestablish standard of care in the face of potential competition?

Thanks, Joe. This is Greg. I'll take a stab at both of those. With regard to the exposure levels, the stated level that we were looking for from our Phase I PK study was while we were looking at the free CNP levels. So in the case of VOXZOGO, of course, that's the drug itself. In the case of other molecules, it would be the released active quantity. We were looking for increases of at least 3x on the AUC. And as I mentioned in our prepared remarks, we actually saw 3 different dose levels where we achieved that in that ongoing Phase I study. So in our dose ranging, again, we'll have an opportunity to test a variety of levels that met that criteria. With regard to the change in AGV over VOXZOGO, not ready to comment today on an actual number. Sorry to disappoint you there. I will add, though, that we have looked at this very closely, spoken with both clinicians as well as patients, and we've determined a level of differentiation that we think will be not only clinically meaningful, but also has the potential to pull through to the endpoints that really count, which are not just linear growth, but are all of those measures of health and wellness and function that we think, again, these patients deserve from a next-generation therapy.

The next question comes from Jessica Fye of JPMorgan.

I had a couple on the guidance and a couple on the pipeline. On the guidance, I don't have FactSet. What is the 2027 FactSet consensus, excluding ROCTAVIAN, just we know what that lower bound is? And then the second one on the guidance, maybe just asking about the other 2 elements of the longer-term targets that I don't think Cory mentioned. Should we still expect 40% non-GAAP operating margin starting in '26 that could expand to the low to mid-40s and the greater than $1.25 billion of CFO starting in 2027? Or were those sort of top line dependent and more in question now? And then the 2 on the pipeline, for 351, my understanding is we'll get 6-month biopsy data for the 6-milligram cohort. What should we expect for the 9-milligram cohort? And second one on the pipeline is for hypochondroplasia, can you remind us of the powering for that trial? And is that fig sufficient in your mind? Or is there some minimum delta on efficacy you want to see to meet your target product profile?

Thanks, Jess. This is Brian. I'll speak to those first couple. So first, just to clarify that FactSet math for you, we are showing FactSet total revenue consensus for 2027 of $3.725 billion, and that includes $75 million of ROCTAVIAN. So that without ROCTAVIAN consensus would be $3.65 billion in '27. And then with respect to the 40% operating margin target next year, that does remain our target. Just a reminder that we've grown profitability and operating margin significantly over the last 2 years due to our strong underlying execution and the focused cost transformation, we do expect that to continue heading into next year and hold that 40% target. I will say that our operating margin objective is rooted in driving efficiency in the business through cost and process transformation, but without compromising value-creating activities. So in the event, in the lower end scenario over time, if we do face a trade-off, and this is less next year or more beyond, if we face a trade-off between preserving those value-creating activities and hitting the 40% margin, we will prioritize value creation to maximize long-term shareholder value. But right now, cost transformation and the target for next year is on track. We'll be prepared to update that again when we issue '26 guidance early next year.

Thanks, Jessica, and this is Greg. Let me take your 2 pipeline questions. With regard to 351, just as a reminder, what you can anticipate is a top line result that will be a combination of all the safety data that we have. That will be the 6-milligram and the 9-milligram per kilogram cohorts as well as the early data that we have, we'll be looking at the 12 milligram per kilogram, which is currently enrolling. What we will be also looking at is biopsy results and dystrophin levels from muscle biopsies in both the 6 and the 9-milligram per kilogram cohort. Our goal, again, is to have a level that predicts it steady state that we would be hitting this 10% level, which is a quite ambitious target. That's not correcting for fat and muscle content. That is a level that has yet to be seen in programs targeting exon 51. With regard to hypochondroplasia, we powered the study to measure for an AGV delta similar to what's been seen with VOXZOGO with achondroplasia, though as a quick reminder, the Dr. Dauber data would suggest that growth in hypochondroplasia may be on the order of 1.8 centimeters per year, a little bit more, which gives us confidence again that this is a well-powered study for hypochondroplasia.

Sorry, Jess, this is Brian. I'll come back again because I realized you had another part to your question about that '27 cash flow and that greater than $1.25 billion. So I'll use your words there. That was top line dependent. And therefore, in the lower case scenarios would be somewhat proportional to the overall revenue scenario. But I will say, again, we're generating significant operating cash flow today, almost $370 million this quarter, over $700 million year-to-date. We've got a number of working capital optimization initiatives that we're introducing across the enterprise over the next 2 years. As Alexander touched on with respect to our capital allocation strategy and business development, these cash balances and the sustained cash flow that we're building has the opportunity to be -- opportunity to be deployed as growth capital going forward. So it's a top priority for the company. But in short, that $1.25 billion was tied to the $4 billion.

The next question comes from Paul Matteis with Stifel.

This is Julian on for Paul. You talked about how your views have changed on the market as well as in thinking about some of these best case scenarios and some of these more bearish scenarios. Can you talk about the contributions of potential commercial competition versus the risk to some of these competitors entering the market? And how much do you think could be attributed to your overall view on being able to have a positive outcome in litigation? Just curious on what you think about that. And then further, on the DMD program, can you just talk a little bit more about the 10% bar that you're sort of setting for yourselves there? Obviously, I think a lot of investors believe that the bar for regulatory approval is meaningfully lower when thinking about exon skippers that are currently approved. So just thinking about what sort of informs that view and if there's any sort of outside case that you could push a program forward that doesn't meet that bar.

Thanks for the question. This is Brian. I'll start with just outlining those bookends of the lower case estimates and the higher case estimates again. And then I'll hand it over to Cristin to make a couple of remarks on the specific market trends we're observing. So for the sake of making these assumptions and developing these -- the lower end of these estimate scenarios, again, we took the assumption that 2 competitors come to market and that by the end of '27, they've been successful with their launch and take significant share. And then in the higher case estimates, and there's a range in between outcomes, of course, that includes either less competition or success with our intellectual property defense. And again, neither of those are our official forecast. We are illustrating what the revenue impact of those potential outcomes could be over time. And again, at the lower end, comfortable with consensus today. In the higher end, we can still get back to $4 billion. And again, this is excluding ROCTAVIAN. Cristin, do you want to comment on that?

Yes Brian. And so yes, so looking at the overall trends, I just want to note what Brian, you said earlier and we said in the prepared remarks, and that is that we have continued to add patients on treatment with VOXZOGO quarter-over-quarter, and that is worldwide. Now if we dig a little bit into the U.S. market in particular, we do see that the majority of those new patient adds is for children under 2 years old. And we want to see that, right? This is patients getting on treatment early. The international guidelines also reiterate the importance of this. And what we see is our adherence rates are remaining strong. And importantly, we are expanding the prescriber base primarily or mostly in the pediatric endocrinology specialty. But what we've also seen in the U.S., and this is not unexpected for something it's fourth year into launch, we are seeing a slower rate of growth in the older patients. Now we expected this to some extent. One, many of these patients are geographically dispersed and in different parts of the country and therefore, harder to find. Not to mention, they're being managed by different specialties. But I will say that the team has been very focused on drawing out initiatives that will target these patients, and we expect that those initiatives will take a little bit of time to play out. But it's really important that we note that the U.S. is 25% of our overall revenues. And really looking to the ex U.S., which comprises 75% of the revenues, we do reiterate our guidance of $900 million to $935 million this year alone. And if we look into the future, we continue to see VOXZOGO as a strong growth engine for us. This is a product that, as Brian has said, has been first to market in achondroplasia. We expect the same in hypochondroplasia, and we have a robust life cycle management plan behind it, launching in new indications over time, not to mention our asset BMN 333. So an important growth engine for us, but it's important to note the trends and the dynamics that we're seeing in the markets today.

Thanks, Julian. This is Greg. Just if I could tackle the DMD question, if that's okay. Yes, we have set a pretty ambitious bar with the 10% level. Just to back up a little bit, of course, Duchenne's muscular dystrophy, the name of the game is opening a therapeutic window in these patients and delivering meaningful results. We've made some choices with the way we've engineered this molecule. We've chosen to use so-called phosphorothioate chemistry instead of what most exon skippers use, the morpholino approaches. That opens this opportunity, again, to open a large therapeutic window for what we think will be a potentially dramatic effect. There are some challenges associated with that as well, though. Weekly administration is required. And the reality is that steady state because of the very long tissue half-life will be out at a year or more. And so what we've done is we've set an ambitious target. We know that we're looking at biopsies at the 6-month time frame. Now as a quick reminder, if we see something between about 3% and 5% at 6 months, that will translate in our model to 10% at steady state. We chose that number because of the human genetic data that suggests dramatically improved functional outcomes in patients that reach those sorts of levels, similar more to a Becker's muscular dystrophy. And we think in the face of some of the characteristics of this molecule, we think that, that sort of doubling of dystrophin as compared to some of the data that's been produced with other exon 51 skippers would be an undeniable advance in the field. And so while we also will be looking, of course, at functional data, we'll look at the totality of the data, that 10% bar is our true north right now to deliver something meaningful for patients.

The next question comes from Chris Raymond of Raymond James.

Just 2 actually for me. And Brian, I heard what you said about '27 not being guidance, just a sort of range of outcomes, but -- so I won't say it's this way. But is it safe to say you're more concerned about TransCon CNP [indiscernible]? And I guess it is -- when you talk about that FactSet number being sort of the low end, is it your assumption that Ascendis gets first cycle approval with just 1 year's worth of data when their PDUFA date comes next month? Or does that even -- does that factor into your thinking? I know it's a little bit removed from 2027, but just kind of are you getting that granular in your thinking? And then maybe an M&A question, Alexander. You guys talk about wanting assets that are under resourced and could be better served by the BioMarin infrastructure or the Inozyme asset, 401, can you maybe talk about how you have leveraged and improved upon Inozyme's efforts in terms of patient identification, outreach, other things that you've done to make that asset better?

Thanks, Chris. This is Brian. I'll start. I appreciate the question. With respect to the 2 potential competitors, first, I'll say I don't think we're going to comment on them versus each other, one versus another. But I will say, this is, I think, the heart of your question, what we've assumed in those lower case estimates that I referred to in that lower end of the range, we have assumed middle-of-the-road assumptions with respect to that -- those companies communicated time lines for their approval, one of which has a PDUFA next month, as you noted. And then following those action dates and communicated approval and launch time lines by those other companies, we then model what a successful launch for those competitors could look like. And that's where we get to this point of the lower end estimate where VOXZOGO remains a growth product for us over these next 2 years. But I think that's all that we'd have to say at this time.

Chris, I'm going to -- I'll take the first part of the question and hand it over to Greg because obviously, 401 is very much in the development stage right now. But overall, what BioMarin is now is we're executing rare disease at scale. I mean we're in 80 countries with an incredible muscle. And we're confident that that's going to magnify the potential impact and ability to reach patients with these genetic conditions all around the world. Our capabilities, the ability to find patients to start them on therapy and then keep them on therapy, these are capabilities we've built over 20 years. So very confident that should this product be approved, we'll be able to leverage that and achieve significant things for 401. But right now, our focus is on the execution of the clinical program, and I'll hand it over to Greg.

Thanks, Alexander. Yes, Brian, just as a quick reminder, again, the deal closed on July 1. So we're not quite 4 months into the integration at this point. It's premature to cite, I think, too many examples of the impact that, that scale of our capabilities and resources can have on the totality of the program. It is very early days. But I will reassure you again that we're leveraging all of our capabilities, whether it's interacting with regulators around the world, whether it's looking for additional indications. And that first -- that first sign, I think, that we'll be able to talk about in future calls will be our preparation that's ongoing for an adult indication in this ENPP1 deficiency area. We're very much looking forward to taking this asset that the Inozyme team, quite frankly, did a remarkable job being able to recruit these very difficult to find patients, difficult to reach patients on to a pivotal study. And we're looking forward to turning the card over for the ENERGY-3 study in the first half of next year.

The next question comes from Sean Laaman with Morgan Stanley.

I just get your latest thoughts on orphan drug exclusivity, kids under 5 and what you think about the potential switching to a competitor as the first one. And the second one, if I'm getting the narrative right, without business development, BioMarin is a capital accumulator. Just to get your thoughts on what you think your balance sheet capacity is and what you see as an efficient balance sheet structure.

Sean, this is Cristin. I'll take the first question. And I think it really comes down to that element of a patient switching. So assuming -- as we're looking at there being a potential for more therapies on the market for the treatment of achondroplasia, we do think that there's a distinct difference between patients that are new to therapy that are naive and the choices that they will make and importantly, those that are already on therapy and seeing great efficacy. So what we hear in both our market research and in our conversations with physicians and families alike, we hear that the majority of patients when they are looking at the opportunity to switch, if they are satisfied with their treatment, they will more likely than not remain on therapy. Now of course, some will choose not to, but that is irrespective of orphan drug exclusivity. That is just a decision that a physician, caregiver and patient are likely to make in that moment. We do think that the adherence rates that we see on VOXZOGO, which remain really high, are a testament to the product's efficacy and safety for that matter and the impact that patients and families are seeing. And so it really does come down to that element of a decision made between the physician and the family at that time as to whether or not a switch is appropriate, where we think that, that's going to be a different decision than for those that are naive to treatment.

And I'll answer the firepower part of your question there, Sean. This is Brian. We estimate that our total firepower is between $4 billion to $5 billion. We're just reporting $2 billion of cash investments on hand, a significant portion of which is available to invest in future growth. And then with our current and growing EBITDA profile, we do have a chance to leverage our earnings and assuming a reasonable ratio, we believe that in total, we've got $4 billion to $5 billion to deploy as growth capital.

Sean, I just want to jump in. Did you -- was your question around orphan drug exclusivity as well?

Sure. It was.

Okay. I apologize about that. Yes, I mean, we've submitted a petition to the FDA concerning the orphan drug exclusivity for VOXZOGO to assert that. The timing of that is we'll find that out at the time of PDUFA. So we feel evicted of the status and the importance of the incentive with regard to innovation in these orphan diseases, and that's very much in process right now.

The next question comes from Akash Tewari with Jefferies.

This is [ Zakiya ] on for Akash. So you talked about how the lower end of your 2027 scenarios is basically in line with top line rev for consensus, in part due to the changing competitive environment, which includes Ascendis, which had positive data shortly after your initial guide. And now it sounds like we're kind of revising the case estimate ahead of pending Phase III data from Bridge. So number one, why not just wait until the BridgeBio data comes out first half of next year? I mean, should we assume that the lower end of your '27 case is the most conservative case that has seen superior efficacy versus for Bridge? And then in the most bullish scenario, it sounds like you're either modeling at most $4 billion or lower in rev. Just wanted to confirm that I have that correct.

Thanks for the question. And yes, I tried to capture the primary takeaway from this exercise, which is that we've modeled a significant level of scenarios across all of our portfolio, across all markets and given the various key assumptions. We did that given the significant level of investor interest on the topic. We appreciate that when we gave the original $4 billion guidance at Investor Day last year, that was before seeing the first competitor data here and have made some updates along the way but really outlining the full range of outcomes and including a lower case that has 2 competitors launching successfully, but yet our revenue still landing at current consensus for '27, we thought would be useful. I am not characterizing that as a worst-case scenario nor am I characterizing the $4 billion as a best case scenario. We just decided to share with you a range of our lower case estimates and our higher case estimates. And on the upside, that would include, I mentioned as an example, intellectual property defense success, but it could also include success across the entire portfolio or competing successfully.

That concludes the Q&A portion of the call. I will now turn it back to BioMarin's President and CEO, Alexander Hardy.

Thank you, operator. We are pleased with the third quarter results across the business, leading us to raise full year total revenues guidance at the midpoint and reaffirm our VOXZOGO revenue outlook for 2025. We have delivered expanding profitability and significant growth in operating cash flow, bringing our cash and investments balance to approximately $2 billion as of the end of the third quarter. Our financial performance so far this year reflects strategic investments in the Enzyme Therapies and Skeletal Conditions business units, both of which remain central to our growth strategy. Building on this momentum, we look forward to the many data readouts and potential new approvals ahead, along with new potential business development opportunities as we focus on the next stage of BioMarin's growth. Thank you for joining us today. We look forward to speaking with you all soon.

This concludes today's conference call. Thank you for joining. You may now disconnect.