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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

Updated 10 mins ago - Science

Blizzard likely to hit New England this weekend as "bomb cyclone" forms

Computer model projection of the precipitation and wind field from the weekend storm in the Northeast. (Earth.nullschool.net)

A powerful blizzard is likely to strike parts of New England and the Mid-Atlantic beginning Friday and lasting into the weekend, with snow totals that are likely to be measured in feet.

The big picture: The joining of weather systems embedded in both the polar, or northern branch, of the jet stream and the southern branch is projected to create a bomb cyclone. Such storms undergo a process known as bombogenesis, with their minimum central air pressure readings plunging at least 24 millibars in 24 hours.

Schumer vows to confirm Breyer replacement "with all deliberate speed"

Chuck Schumer. Photo: Alex Wong/Getty Images

Senate Majority Leader Chuck Schumer responded Wednesday to reports that Supreme Court Justice Stephen Breyer will retire, commending his time on the bench and promising to confirm President Biden's nominated replacement "with all deliberate speed."

Why it matters: The opportunity to appoint a new Supreme Court justice will be one of the longest-lasting pieces of Biden's legacy and could energize Democrats ahead of the midterms.

52 mins ago - World

Scoop: Israel's "top priority" mission to discredit UN probe

Israeli Prime Minister Naftali Bennett addresses the UN. Photo: John Minchillo/Pool via Getty

Israel is planning a campaign to discredit a UN commission formed to investigate the violence in Gaza last May and the root causes of the protracted conflict in the occupied West Bank and Gaza, according to an Israeli Foreign Ministry cable seen by Axios.

Why it matters: Israeli officials say they are highly concerned that the commission’s report will refer to Israel as an "Apartheid state" and that its findings could damage Israel's reputation, particularly among progressives in the West. The report is expected in June.