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Illustration: Sarah Grillo / Axios

Pharmacy benefit managers play an important but secretive role in controlling the prices of prescription drugs — and they're working hard to keep it that way. After Axios obtained a document that shed new light on this opaque process, Express Scripts, the country’s largest PBM, forced that document to be taken down.

Why it matters: Americans fill 4.5 billion prescriptions per year. The biggest pharmacy benefit managers are profiting from the vast majority of those transactions, largely through sophisticated and complex financial engineering. Critics argue these tactics contribute to the country's high drug prices, which makes it important to understand how all of this works.

The big picture: Pharmacy benefit managers, or PBMs, are middlemen. They administer the prescription drug coverage in employers’ health care plans, which includes negotiating for discounts with the pharmaceutical companies.

  • Critics say PBMs keep a lot of those savings for themselves, rather than passing them on to consumers. PBMs say they’re providing real value. But their contracts are highly complex and secretive, making it hard to determine who’s right.

Axios obtained a document that helps answer those questions — a copy of the template that Express Scripts uses for its contracts. We reported on its contents, and posted the document itself to DocumentCloud so readers could evaluate it for themselves.

  • Express Scripts dismissed the document as out of date and irrelevant.
  • But after our story ran, the company’s lawyers forced DocumentCloud to remove the contract template, claiming copyright infringement.

What’s next: In lieu of reposting the entire Express Scripts contract template, this series takes a fresh and more detailed look at some of the most important tactics large PBMs use to protect their financial interests. It is based on portions of the Express Scripts template as well as new reporting and pharmacy benefits documents. Express Scripts declined multiple requests to comment further.

Go deeper

Mike Allen, author of AM
6 hours ago - Politics & Policy

Biden adviser Cedric Richmond sees first-term progress on reparations

Illustration: "Axios on HBO"

White House senior adviser Cedric Richmond told "Axios on HBO" that it's "doable" for President Biden to make first-term progress on breaking down barriers for people of color, while Congress studies reparations for slavery.

Why it matters: Biden said on the campaign trail that he supports creation of a commission to study and develop proposals for reparations — direct payments for African-Americans.

Cyber CEO: Next war will hit regular Americans online

Any future real-world conflict between the United States and an adversary like China or Russia will have direct impacts on regular Americans because of the risk of cyber attack, Kevin Mandia, CEO of cybersecurity company FireEye, tells "Axios on HBO."

What they're saying: "The next conflict where the gloves come off in cyber, the American citizen will be dragged into it, whether they want to be or not. Period."

Cedric Richmond: We won't wait on GOP for "insufficient" stimulus

Top Biden adviser Cedric Richmond told "Axios on HBO" the White House believes it has bipartisan support for a stimulus bill outside the Beltway.

  • "If our choice is to wait and go bipartisan with an insufficient package, we are not going to do that."

The big picture: The bill will likely undergo an overhaul in the Senate after House Democrats narrowly passed a stimulus bill this weekend, reports Axios' Kadia Goba.

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