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Illustration: Sarah Grillo / Axios

Express Scripts met with analysts at banking giant Barclays in March and mentioned how its "industry-leading EBITDA per claim" — a measure of profit they collect on each prescription — likely will be "sustainable over time," according to Barclays' note to Wall Street. Those comments come as each of the big three pharmacy benefit managers are being attached to health insurers.

The big picture: Some PBMs use a different "transparent" model to earn money, but they are in the minority. New documents obtained by Axios peel back the curtain on the traditional drug benefits business, though many details remain hidden from public view.

Some new documents shed light on how PBMs make money, and also reveal how difficult it is to get the full picture:

  • Nashville uses Express Scripts to provide drug benefits to city employees, and its publicly available 2017 contract lays out actual financial terms — including rebates. Many of the contract's definitions are also identical to the template Axios previously published — including the brand/generic algorithm.
  • The state of Delaware amended its contract with Express Scripts a few years ago to ensure that Express Scripts guaranteed more rebates, according to a copy of the contract.
  • Axios obtained an OptumRx pharmacy benefits proposal through New Jersey's open records law. New Jersey awarded its pharmacy benefits deal to OptumRx last year. However, several sections that outline financial terms for the taxpayer-funded prescription drug deal are "exempt from public disclosure." OptumRx did not respond to questions.

What we're hearing: Many people that work in the industry are voicing disdain for the business models and lack of transparency associated with the main players.

  • West Virginia's Medicaid program kicked PBMs to the curb last year. The state uses health insurers to run Medicaid, and it said it would no longer pay insurers to contract with CVS and Express Scripts for pharmacy benefits.
  • Vicki Cunningham, West Virginia's director of pharmacy, said the PBM costs were "excessive" and "not sustainable." The state expects to save $30 million this year by acting as its own pharmacy benefit manager.
  • Arkansas passed a law requiring PBMs to be licensed through the state's insurance department.
  • Ohio lawmakers are looking into how health insurers pay PBMs and how PBMs pay pharmacies, according to the Columbus Dispatch.

Go deeper: A Bloomberg story on how PBMs book their profit, and the American Prospect on PBM antitrust concerns.

Other parts of the series:

Go deeper

Scoop: 50,000 migrants released; few report to ICE

A law enforcement officer walks to meet migrants crossed the Rio Grande River illegally last month. Photo: Brandon Bell/Getty Images

About 50,000 migrants who crossed the southern border illegally have now been released in the United States without a court date. Although they are told to report to an Immigration and Customs Enforcement office instead, just 13% have showed up so far, Axios has learned.

Why it matters: The sizable numbers are a sign of just how overwhelmed some sectors of the U.S.-Mexico border continue to be: A single stretch covering the Rio Grande Valley had 20,000 apprehensions in a week. The figures also show the shortcomings of recent emergency decisions to release migrants.

1 hour ago - World

Scoop: Israel launches maximum pressure campaign against Ben & Jerry's

A Ben & Jerry's store in Yavne, Israel. Photo: Ahmad Gharabli/AFP via Getty

The Israeli government has formed a special task force to pressure Ben & Jerry's ice cream and its parent company Unilever to reverse their decision to boycott Israeli settlements in the West Bank, Israeli officials tell me.

Why it matters: The Israeli government is concerned the move by Ben & Jerry's will encourage other international companies to take similar steps to differentiate between Israel and the West Bank settlements. A classified Foreign Ministry cable, seen by Axios, makes clear the government wants to send a message.

Video game developers at Activision Blizzard say they'll walk out Wednesday

Illustration: Shoshana Gordon/Axios

Employees at Activision Blizzard will hold a walkout Wednesday in protest of widespread harassment allegations across the company, a spokesperson on behalf of the group told Axios.

Why it matters: Walkouts are a drastic measure for developers in a largely non-unionized field, a testament to just how angry employees currently are.