Pomona, CA—Since the FDA approval in 2019, the combination of sacubitril/valsartan has been recommended by clinical practice guidelines to reduce mortality and morbidity in patients with heart failure with reduced ejection fraction (HFrEF).
Yet, despite arguments that prescription of the first-in-class angiotensin receptor-neprilysin inhibitor (ARNI) is superior to standard care in those patients and has the potential to reduce the overall burden of HF, uptake has been slow.
A new study published in Circulation: Cardiovascular Quality & Outcomes posits why that is the case. Western University of Health Sciences, College of Pharmacy researchers and colleagues characterized prior authorization (PA) burden, prescription copayment, and utilization of sacubitril/valsartan by insurance plan type to identify potential barriers to its use.
The study team conducted a national population-level, cross-sectional study using PA data from an insurance coverage website accessed in March 2019 and IQVIA National Prescription Audit data from August 2018 to July 2019. Defined as primary outcomes were the proportion of plans requiring PA, frequency of specific PA criteria, number of sacubitril/valsartan prescriptions, and copayments per insurance plan type.
Results indicate that, overall, nearly half, 48.1% (1,394/2,896), of insurance plans required PA for sacubitril/valsartan, although fewer Medicare (27.7%) than commercial (57.2%) plans had that hurdle.
“For both plan types, the most frequently required PA criteria were ejection fraction (71.6%, 90.9%) and New York Heart Association class (60.4%, 90.8%) for Medicare and commercial plans, respectively,” the authors note.
The study team also reports that copayment amounts varied by plan type, but more commercial plans didn’t require patient copayment for sacubitril/valsartan prescriptions (32.4%) than with Medicare plans (19.3%; P <.001).
The study estimates 814,437 sacubitril/valsartan prescriptions for Medicare and 822, 292 for commercial plans dispensed from August 2018 to July 2019.
“Based on estimated heart failure with reduced ejection fraction populations for each plan type, 4-fold more sacubitril/valsartan prescriptions were dispensed in commercial than in Medicare plans (820 versus 215 prescriptions/1,000 individuals in the heart failure with reduced ejection fraction population),” the researchers point out.
The differences were significant, with the estimated proportion of HFrEF patients prescribed sacubitril/valsartan at 3.6% (1.5%-6.8%) for Medicare versus 13.7% (4.9%-31.8%) for commercial plan populations.
“Despite commercial plans having greater PA requirements than Medicare, population-adjusted use of sacubitril/valsartan was higher in commercial plans,” the authors conclude. “Given that commercial plans had more prescriptions with low copayments than Medicare, copayment policies may be more influential on sacubitril/valsartan use than its PA policies. Low sacubitril/valsartan use in both plan types highlights the multifactorial nature of medication underutilization that includes factors beyond the drug policies that we evaluated.”
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