How do PBMs and rebates shape competition in ATTR-CM?
An incumbent with a large patient base can offer larger total rebates — and PBM income is often tied to list price — a dynamic the FTC's Express Scripts and Caremark settlements in insulin are now trying to dismantle by delinking fees from list prices.
ATTR-CM stabilisers are pharmacy drugs, so their placement on PBM formularies strongly influences which one patients receive. In Medicare Part D, manufacturers pay rebates to PBMs, which share them with plans, to secure formulary inclusion or preferred status, sometimes while excluding competitors. The logic critics highlight is that a dominant incumbent, such as Pfizer, can offer larger total rebates across a big patient base, and that PBM income is often tied to list price. The FTC's settlements with Express Scripts and Caremark over insulin now require them to delink PBM fees from list prices and stop discriminating against lower-cost options, reforms that could spill over into ATTR-CM.