Fighting for Better Access to Life-Saving Heart Failure Therapies

Volume 16, Issue 4

The drug therapy landscape for patients with heart failure and a reduced ejection fraction (HFrEF) has drastically changed over the last 7 to 8 years. As recently as 2015, patients could be on effective triple therapy with a generic angiotensin-converting enzyme (ACE) inhibitor, beta-blocker, and mineralocorticoid receptor antagonist (MRA) and pay relatively little out-of-pocket.

The more recent additions to the drug therapy armamentarium—angiotensin receptor neprilysin inhibitor (ARNI) and sodium-glucose cotransporter-2 (SGLT2) inhibitors—both provide substantial further reductions in HF-related morbidity and mortality. As such, the most recent 2022 Heart Failure Guidelines strongly advocate for quadruple therapy with the combination of an ARNI, SGLT2 inhibitor, beta-blocker, and MRA for all patients with HFrEF.

Unfortunately, the introduction of drugs with branded copays will inevitably lead to higher prescription costs for patients. In this week’s issue of Talking Therapeutics, we explore a new study on the out-of-pocket costs for quadruple therapy in patients with HFrEF.

Point 1: Restricted Coverage Nearly Universal

The current study involved all 4068 Medicare prescription drug plans implemented in 2020. Study authors analyzed cost sharing, prior authorization, and step therapy. Here are the key findings:

• Tier ≥3 cost sharing was required by 99.1% of plans for ARNI and 98.5% for at least 1 SGLT2 inhibitor.
• Only ARNI required prior authorization (24.3% of plans), and step therapy was required only for SGLT2 inhibitors (5.4%) and eplerenone (0.8%).
• The median 30-day standard coverage out-of-pocket cost of quadruple therapy was $94 (IQR: $84-$100), including $47 (IQR: $40-$47) for ARNI and $45 (IQR: $40-$47) for SGLT2 inhibitors.
• The median annual out-of-pocket cost of quadruple therapy was $2217 (IQR: $1956-$2579) compared with $1319 (IQR: $1067-$1675) when excluding SGLT2 inhibitors, and $1322 (IQR: $1025-$1588) when including SGLT2 inhibitors and substituting an ACE inhibitor or angiotensin receptor blocker for ARNI therapy.
• The median 30-day out-of-pocket cost of generic regimens was $3 (IQR: $0-$9).

Point 2: We Don’t Need Another Barrier

The findings of the present study are frankly disappointing, given that many barriers to effective implementation of quadruple therapy already exist.

One of these barriers is clinical inertia, which is the phenomenon where clinicians are less prone to using new therapies based on old habits. Others include lack of knowledge regarding the benefits of quadruple therapy, drug-related side effects, and limited time in the clinic space to make complicated medication adjustments during an office visit.

Adding financial barriers for these life-saving medications only makes the situation worse. Ultimately, the onus for fixing this problem lies with the Centers for Medicare & Medicaid Services, which should strongly reconsider this cost-sharing policy. It would be in their best interest to do so, given widespread use of quadruple therapy would reduce more costly interventions down the line, such as a HF-related hospitalization.