Medicare drug plans may limit coverage of quadruple drug therapy for heart failure with reduced ejection fraction (HFrEF) through cost sharing, resulting in out-of-pocket (OOP) costs considerably higher than generic regimens and potentially unaffordable for many Medicare patients, according to a study published June 20 in the Journal of the American College of Cardiology.

Kamil F. Faridi, MD, et al., assessed cost sharing, prior authorization and step therapy in the 4,068 Medicare prescription drug plans active in 2020. They found that the median 30-day standard coverage OOP cost for quadruple therapy was $94, and the median 30-day OOP cost of generic regimens was only $3. In addition, the median annual OOP cost for quadruple therapy was $2,217. When excluding SGLT2i or ARNI, the median annual OOP cost dropped to $1,319 and $1,322, respectively.

Results also showed that while nearly 100% of Medicare prescription drug plans provided coverage of all classes of quadruple drug therapy, almost all these plans limited this coverage through tier level 3 cost sharing, a barrier which may not be known by prescribing physicians.

The authors conclude that “clinicians should assess whether OOP costs are affordable or may be leading to nonadherence among patients who are prescribed ARNI and SGLT2is.”

In an accompanying editorial comment, Jason H. Wasfy, MD, MPhil, FACC, and Anna C. O’Kelly, MD, emphasize the efficacy of quadruple therapy for patients with HFrEF, and highlight the importance of reconsidering what is appropriate for drug prices and coverage.

“A core function of both private insurance companies and government payers is moderating increases in health care costs,” write Wasfy and O’Kelly. “The work by Faridi et al., demonstrates that without consensus on cost-effectiveness from the societal perspective, costs can be imposed directly on patients in ways that slow uptake of cost-effective drugs.”

Clinical Topics: Cardiovascular Care Team, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Acute Heart Failure

Keywords: Physicians, Cardiology, Government, Health Care Costs, Cost Sharing, Medicare, Stroke Volume, Prior Authorization, Heart Failure, Consensus, Cost-Benefit Analysis, Health Expenditures, Prescription Drugs, Aged, ACC Advocacy

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