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

Updated 18 mins ago - Politics & Policy

Tim Scott says Trump "misspoke" when he told Proud Boys to "stand by"

Photo: Bonnie Cash/Pool/AFP via Getty Images

Sen. Tim Scott (R-S.C.) told reporters on Wednesday that he believes President Trump "misspoke" when he told the far-right "Proud Boys" group to "stand back and stand by" in response to a question about condemning white supremacy at the first presidential debate.

Catch up quick: Moderator Chris Wallace asked Trump on Tuesday, "Are you willing, tonight, to condemn white supremacists and militia groups and to say that they need to stand down?" Trump asked who specifically he should condemn, and then responded, "Proud Boys, stand back and stand by. But I'll tell you what, somebody's got to do something about antifa and the left."

Updated 26 mins ago - Politics & Policy

Commission on Presidential Debates wants changes

Photos: Jim Watson and Saul Loeb/AFP via Getty Images

The Commission on Presidential Debates announced Wednesday that it plans to implement changes to rules for the remaining debates, after Tuesday night's head-to-head between Joe Biden and Donald Trump was practically incoherent for most of the night.

What they are saying: "Last night's debate made clear that additional structure should be added to the format of the remaining debates to ensure a more orderly discussion of the issues," the CPD said in a statement.

Trump says he doesn't know who Proud Boys are after telling them to "stand by"

President Trump told reporters on Wednesday that he doesn't know who the "Proud Boys" are, after saying at the presidential debate last night that the far-right group should "stand back and stand by" in response to a question asking him to condemn white supremacists.

Why it matters: The comments set off outrage and calls for clarification from a number of Republican senators. After being asked several times on Wednesday whether he will condemn white supremacy, Trump responded: "I have always denounced any form — any form of any of that, you have to denounce. But I also — Joe Biden has to say something about antifa."

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