Axios : The drug pricing contract Express Scripts doesn't want you to see

The drug pricing contract Express Scripts doesn't want you to see
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  • Express Scripts dismissed the document as out of date and irrelevant.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.

(Stifel) Wal-Mart: Amazon drives Walmart to consider closer relationship with Hu

Wal-Mart: Amazon drives Walmart to consider closer relationship with Humana (HUM)
Stifel notes that, according to The WSJ, Walmart is in early discussions with Humana (HUM) involving a range of options, potentially including an acquisition. They believe an outright acquisition would be modestly accretive to Walmart earnings and potentially additive to store traffic, though would also meaningfully increase business complexity and risks. While they have no knowledge of any M&A negotiations or discussions, additional media reports suggest an expansion of an existing prescription drug plan partnership is most likely. They view this as a more favorable near-term option in that it would allow Walmart to learn more about the healthcare industry, and likely include closer ties that could add to Walmart's store traffic while also potentially reducing costs.

>>> Salesforce to adopt Financial Accounting Standards Board accounting standard

Salesforce to adopt Financial Accounting Standards Board accounting standards; adjusts Q1 and FY19 guidance to reflect new standards (116.30)
  • Co intends to adopt Financial Accounting Standards Board accounting standards ASC 606 and ASC 340-40.
  • To reflect new accounting, co raised guidance for Q1 (Apr), sees EPS of $0.46-0.47 from $0.43-0.44 vs. $0.44 Capital IQ Consensus Estimate; sees Q1 (Apr) revs of $2.935-2.945 bln from $2.925-2.935 bln vs. $2.93 bln Capital IQ Consensus Estimate.
  • Co raised guidance for FY19 (Jan), sees EPS of $2.25-2.27 from $2.02-2.204 vs. $2.04 Capital IQ Consensus Estimate; sees FY19 (Jan) revs of $12.66-12.71 bln from $12.60-12.65 bln vs. $12.68 bln Capital IQ Consensus Estimate.

FT : Sunni Saudi Arabia courts an ally in Iraq’s Shia

Sunni Saudi Arabia courts an ally in Iraq’s Shia
Can the kingdom and its reconstruction aid overcome distrust between Islamic sects?


Beneath the golden dome of the Imam Ali shrine spreads the ramshackle expanse of Najaf, the Iraqi holy city for Shia Muslims, who flock to it in their thousands. Arab visitors bow as they pass the shrine, Iranians sitting beneath it recite lilting chants and Pakistani worshippers rhythmically beat their chests. 

With little in the way of wealth or resources, Najaf might seem an unlikely place for anyone but Shia pilgrims to seek out. Yet the city, 160km south of Baghdad, has an unusual new suitor — the oil-rich power on the other side of Islam’s sectarian divide, Saudi Arabia. The Sunni Gulf kingdom’s courting of Iraq’s Shia clerical elite over the past year could mark a transformational shift in Riyadh’s regional strategy. 

For decades, Saudi Arabia and its Shia rival Iran have exploited the centuries-old schism between Islam’s Shia and Sunni sects to serve their modern-day power struggles. Now, Saudi officials are discreetly shuttling messages to Najaf’s leading Shia clerics, who, although wary of being drawn into a proxy struggle, want to hear Riyadh out. Last year foreign minister Adel al-Jubeir made the first visit to Iraq by a senior Saudi official since 1990. Iraqi leaders have hinted that Crown Prince Mohammed bin Salman could also visit the country soon, with some saying he would include Najaf on any itinerary. But the Saudi foreign ministry was forced on Saturday to issue a statement saying that no such trip was planned, after a protest in Baghdad at the end of last week against such a visit.

The stakes of this tentative rapprochement are high. At its best, Riyadh’s efforts to find Shia allies against Iran could defuse sectarianism that has sewn a bloody trail of conflict across the region. At its worst, the push could turn Iraq into yet another stage for Iranian-Saudi rivalries, played out most recently in Yemen, Syria and Lebanon.

“It may be calm in Iraq now . . . but the struggle between these two forces is reaching a climax, and I don’t see either side ready for dialogue,” says the Iraqi Shia politician Ali al-Adib. “This is a region pregnant with surprises.”

Iraq and its Gulf Arab neighbours have been estranged since the 1991 Gulf war, triggered by former ruler Saddam Hussein invading Kuwait. Opportunities to re-engage crumbled after the 2003 US invasion — with the long-repressed Shia majority suddenly empowered and facing hostility from Sunni factions, many leaders turned to Tehran. Iran’s Revolutionary Guards bolstered Iraq’s hardline Shia militias. Meanwhile, Iraqis accused Gulf states, particularly Saudi Arabia, of tolerating if not funding Sunni jihadi groups like al-Qaeda and more recently Isis that were fuelling civil war in their country.

Saudi re-engagement with Iraq has long been encouraged by western powers, particularly the US. Those efforts were bolstered last year by visits by two influential Iraqi Shia leaders, Muqtada al-Sadr, a popular cleric and political leader, and Haider al-Abadi, prime minister. Now Prince Mohammed appears to have embraced this strategy as a way to challenge Iran’s expanding regional influence, while he embarks on a radical overhaul of his own country’s economy. 

“Saudi Arabia has realised that it cannot do without coexisting with, or tolerating Shiism,” says Diya al-Assadi, an Iraqi parliamentarian close to Mr Sadr. “Now, the Saudis want to tell people that they are not against Shiism, but they are against Shiism influenced by Iran.”


Fans cheer the Iraq football team during their match against Saudi Arabia in Basra, their first game inside the country since the 1980s. Despite losing 4-1, the Saudi king promised to build a 100,000-capacity stadium in the Iraqi capital © AFP
The approach chimes with some Shia worried by Iran’s increasingly powerful role in the country. Najaf clerics have long been leery of Iranian interventionism. Some Shia politicians, riding a wave of Iraqi nationalism after defeating Isis, are playing up their shared identity with the Gulf Arab states as part of their bid to gain support for Iraq’s estimated $88bn reconstruction effort. They see development as key not only to rebuilding after a three-year war against Isis, but ending the decade-long cycle of sectarian violence that preceded it.

“Our hope is that these Arab countries hurry up and enter the market,” says Ahmed al-Kinani, a Shia politician who heads parliament’s economic committee and who was formerly aligned with pro-Iran parties. “Iraq is an important part of the Arab world, and Iraq should return to the Arab embrace.”

The Saudi charm offensive contrasts starkly with Prince Mohammed’s earlier attempts at countering Iran. Its air war against Shia Houthi rebels in Yemen has left thousands dead and created a quagmire from which there is no easy exit. A brazen move last year to hold its Sunni ally, Lebanese prime minister Saad al-Hariri, in Riyadh and force him to resign in a bid to push the Iranian-backed Hizbollah group out of government backfired.

Yet in Iraq, where Iran’s powerful presence constrains Riyadh’s ambitions, Saudi leaders could get it right.

“Riyadh is laying the groundwork for patient, long-term engagement, doing the hard work of rebuilding ties, relationships and even its public image,” says Elizabeth Dickinson, a Gulf analyst for the International Crisis Group. “We see real potential for Saudi engagement with Iraq to forge a new model in how to whittle back Iranian influence in the region.”

Najaf is a natural target. Its leading clerics wield huge influence over Iraq, and the Shia world more broadly. A major coup for Riyadh would be developing a relationship with Najaf’s Grand Ayatollah. Few clerics are as influential as the elderly, hermitic Ali al-Sistani. In 2014, with a single fatwa (religious decree), he sent tens of thousands of Iraqi men to join paramilitary groups fighting Isis after it seized over a third of the country. 

Mr Sistani’s office, itself critical of Iranian intervention, is still wary of Saudi overtures, local officials say, but has maintained back-channel communications. In Najaf and across Iraq, Riyadh is appealing to a shared Arab identity — something Iraq does not have with Iran’s Persian majority.

In February, the Saudi Arabia football team played Iraq in the southern city of Basra, their first game inside the country since the 1980s, a match attended by 60,000 fans. Despite losing 4-1, the Saudi king promised to build a 100,000-capacity stadium in Baghdad.

The kingdom has also sent delegations of businessmen and journalists, many of whom had not visited the country in decades, fuelling nostalgia for an era before wars tore Iraq apart. Adham Fakher, an Iraqi economist, says some delegates wept as Iraqi officials greeted them. “I was really surprised,” he recalls. “These two communities were genuinely very excited to meet.”


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But that excitement has cooled as Saudi visitors begin to grapple with the daunting scale of Iraq’s corruption problems and devastated infrastructure. A member of one delegation sent a note to the Iraqi National Business Council, Mr Fakher said, detailing concerns over security and Iraq’s banking system, which critics say is outdated, corrupt, and reluctant to fund investment.

Investment is what Baghdad wants most. So far, Iraq has gained new direct flights with Riyadh and the signing of 18 memoranda of understanding for oil and gas projects, but little direct investment. At a recent reconstruction conference in Kuwait, Gulf states offered little aid — the $3.5bn pledged came mostly in loans and credit facilities.

“We thought money was going to come pouring in,” one Iraqi banker says. “After the conference, we felt a lot of it was talk.”

But in Basra, Iraq’s oil and economic hub, the head of the local investment authority, Ali Jassib, remains optimistic: “Even if it’s all talk — it doesn’t matter. It’s still an attempt at a new start and refreshed relations.” The opening of a consulate in Basra is a sign Riyadh aims to support Saudi investors, he says, pointing to talks between Sabic, the Saudi chemical company, and Shell to invest in its $11bn petrochemical project. Meanwhile, Basra’s investment authority aims to attract Gulf money for railway and agricultural projects.

Thaer Abdel-Zahra, one of the owners of Basra’s popular Times Square Mall, says he has noticed a rise in interest from Gulf investors. His partners recently met representatives of Kuwait’s Alshaya group, a major franchise owner, with brands like H&M, McDonald’s and Starbucks. “God willing, within a few months you’ll see a Starbucks downstairs,” he says. 

His concern is that Iranian-backed parties controlling administrative offices may try to strangle Saudi investors’ bids for land and licences, via red tape. “There is a long way and a short way to get these,” he says. “They will push the Saudis the long way.”

Businessmen say US officials are facilitating a lot of the activity to counter Tehran’s influence. Iran, Iraq’s second largest trading partner, exported $12bn worth of goods in the past year according to Iranian state media.


Iraqi leaders have hinted that Crown Prince Mohammed bin Salman could also visit their country soon, with some saying he would include Najaf on any itinerary © Reuters
US involvement worries some proponents of Saudi rapprochement, like Sadr supporters — many of whom once fought US forces. They argue that alongside belligerent anti-Iran rhetoric coming from Washington, it could push Riyadh to over play its hand. “We really don’t want Iraq to end up as the rubbish bin of a regional Iranian-American-Saudi dispute,” says Salah al-Obaidi, a Najaf cleric and relative of Mr Sadr. 

Diplomats say Iran has stayed on the sidelines, trying to assess whether there is any benefit, to it, from a Gulf presence in Iraq. Tehran’s attempt to unify several Shia political blocs to reinforce its position in the country ahead of Iraq’s May parliamentary elections, fell apart within days. “That incident shows us [not to] believe people who say Iran controls everything,” says one western diplomat. “The big card they play is — look, we will always be there for you.”

Many Shia leaders note that it was not Riyadh or Washington but Tehran that rushed to support Iraq when Isis attacked in 2014. “Everyone withdrew and watched to see when we would be finished off,” says a representative for a leading Najaf cleric. “Except Iran.”

Sceptics say Riyadh’s sincerity must be tested through changes to repressive treatment of its own Shia minority. Just two years ago, Riyadh executed the Shia sheikh, Nimr al-Nimr. Others call for an end to the Yemen war, or demand Saudi clerics issue a fatwa declaring Shiism a legitimate branch of Islam.

Supporters of the rapprochement point to recent improvements, such as the treatment of Iraqi Shia pilgrims to Saudi Arabia. Yet suspicions run deep. The day before the Basra football match, signs warning against a Saudi consulate appeared on street corners, before being quickly removed.

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Some Shia leaders argue Riyadh still bears responsibility for the rise of jihadism. “We’ve heard lots of nice speeches, we’ve heard about this new vision of theirs,” the Najaf cleric says. “But we are waiting to see action on the ground.”

Nowhere are these suspicions more potent than among mourners visiting Najaf’s Wadi al-Salam cemetery, the world’s largest, where Iraq’s Shia come to bury their dead near the Imam Ali shrine. At a “martyr’s plot” made for forces loyal to Mr Sadr, a scrawny young man stands over the freshly dug grave of a comrade killed by remnants of Isis. He points out two other graves bedecked in plastic flowers, which belong to his dead friend’s older brothers.

“We understand why we need better relations with Saudi Arabia. But in our hearts, it’s hard to accept.” he says. “We gave martyrs, we gave blood. They’ll compensate with what? A soccer field?”

Additional reporting by Ahmed Al Omran in Riyadh

Najaf: Iranian money evident in holy city

The Imam Ali Shrine in Najaf © AP
When it comes to building influence in Najaf, Iran has more than a decade on Saudi Arabia, making inroads that reveal Tehran’s determination to consolidate its influence. 

Najaf is home to the place where the Imam Ali, seen as a founding figure of the Shia sect, is believed to be buried. The marjaiyat, or top Shia clerics, are hugely influential over the world’s roughly 200m Shia Muslims.

The most visible sign of Iran’s ambitions is the Imam Ali shrine itself. The ancient shrine now has new rooms adorned with brand new marble columns and ornate mirrored ceilings. Concrete foundations for an even larger expansion are visible in the dusty marketplace. 

All of this, local officials say, is managed by an Iranian company reportedly linked to Iran’s Revolutionary Guards. Some Iraqi officials privately raise suspicions that Iranian spies have purchased property near the modest rental home of Grand Ayatollah Ali al-Sistani, a supreme cleric for the Shia world — a move that seems like surveillance.

“The marjaiyat are getting concerned by the influence Iran is gaining inside Najaf, from the expansion of the shrine to an increasing number of Iranians moving to Najaf,” says Renad Mansour, an Iraq analyst at Chatham House.

In 2011, the Iranian cleric Mahmoud Shahroudi, often seen in pictures beside Iran’s supreme leader, opened an office in Najaf which pays stipends to clerical students. It was a provocative move, Sistani supporters say, which shows Iran is vying for one of its own to succeed the role as one of the supreme clerics in the Shia world. 

>>> US Gapping down

Gapping down
In reaction to disappointing earnings/guidance
:

  • SORL -11.4%, SNX -6%

Other news:

  • ALKS -20.2% (receives refusal to file letter from FDA for ALKS 5461)
  • TSLA -4.7% (to recall 123K Model S units; also Tesla says Autopilot was engaged moments before recent collision)
  • FB -1.3% (cautious Barrons mention)
  • RXII -0.9% (filed $100 mln mixed securities shelf offering)

Analyst comments:

  • FIT -5.3% (downgraded to Underweight from Equal-Weight at Morgan Stanley)
  • BOFI -1.3% (downgraded to Outperform from Strong Buy at Raymond James)


>>> US Gapping up

Gapping up
In reaction to strong earnings/guidance
:

  • NA.

M&A news:

  • HUM +6% (WalMart (WMT) is in early talks to acquire HUM, according to WSJ)

Select Macau gaming names showing strength:

  • LVS +1.2%, WYNN +1.2%, MLCO +0.9%

Select metals/mining stocks trading higher:

  • AUY +2.2%, MUX +1.9%, ABX +1.6%

Other news:

  • SENS +15.7% (announced a favorable outcome of the FDA Clinical Chemistry and Clinical Toxicology Devices meeting on the Eversense system)
  • CRK +9.4% (announced a series of related transactions in support of a comprehensive refinancing of substantially all of its existing debt)
  • CGEN +6.7% (entered into an exclusive license agreement with MedImmune)

Analyst comments:

  • DISCA +1.5% (upgraded to Outperform from Market Perform at Wells Fargo)
  • BHGE +1.4% (upgraded to Buy from Neutral at BofA/Merrill)