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Illustration: Sarah Grillo/Axios

We keep mentioning “middlemen” as part of the complex, expensive drug supply chain. They’re actually called pharmacy benefit managers, or PBMs, and their role in the system is both incredibly important and incredibly opaque.

How it works: PBMs are hired by an insurance company or a self-insured employer.

  • Their job is to take care of the prescription-drug coverage for that insurance plan, which includes negotiating with drug companies for discounted prices.
  • PBMs are a big part of the reason overall drug spending has held pretty steady lately, even as sticker prices rise.

The intrigue: PBMs do this through a complex system of rebates, in which they hang onto a percentage of the discounts they negotiate.

  • PBMs' primary business model is drawing increasing scrutiny, as critics suggest it gives them a perverse incentive to play along with higher drug prices. Ohio's Medicaid program, for example, recently forced its PBMs to move to a new system of fixed fees.

Axios was able to bring some light into the darkness of the PBM world earlier this year, after we obtained a copy of a contract template used by Express Scripts, the country’s biggest PBM.

  • That document helped illuminate the many subtle ways these companies are able to tilt the playing field in their favor as they work with employers and insurance plans.

Read the full investigation here to go deeper on a critical part of the health care industry.

Go deeper: Read the rest of Axios' Deep Dive on prescription drug prices

Go deeper

Women rise to the top at major media companies

Illustration: Aïda Amer/Axios

Several women have been tapped to lead some of the country's largest newsrooms over the past year — a promising sign of progress for an industry that's typically been slow to accept change and embrace diversity.

Driving the news: CBS News executive Kimberly Godwin was named president of ABC News on Wednesday. Godwin will be the first Black woman to lead a major broadcast news division when she takes the helm in May.

Americans will likely have to navigate a maze of vaccine "passports"

Illustration: Rae Cook/Axios

Many private businesses and some states are plowing ahead with methods of verifying that people have been vaccinated, despite conservative resistance to "vaccine passports."

Why it matters: Many businesses view some sort of vaccine verification system as key to getting back to normal. But in the absence of federal leadership, a confusing patchwork approach is likely to pop up.

The future of political advertising is connected TV

Reproduced from Centro; Chart: Axios Visuals

Political advertising has quickly begun to migrate over to connected TV (CTV), or digital and streaming television, according to new data.

Why it matters: "If the current trends of explosive growth in CTV viewership continue, we could see a tipping point where CTV makes up nearly half of political digital ad spend as soon as 2022," says Grace Briscoe, vice president of candidates and causes at Centro, a digital ad placement firm that works with hundreds of campaigns across the country.

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