Abstract 267: National Comparison of Prior Authorization and Utilization of Sacubitril/valsartan in Medicare and Commercial Plans in Patients With Heart Failure With Reduced Ejection Fraction
Background: Sacubitril/valsartan (Entresto®) reduces mortality and heart failure (HF) admissions in NYHA Class II/III HF with reduced ejection fraction (HFrEF). However, uptake in practice has been lower than expected. Prior authorization (PA) is a common barrier that may reduce drug access, which may impact clinical outcomes. Our study characterizes PA requirement burden and use of sacubitril/valsartan by insurance plan type.
Methods: We conducted a cross-sectional study using insurance plan information directly from a managed care organization-approved insurance coverage website accessed in Mar/2019 to characterize sacubitril/valsartan PA criteria in Medicare and commercial plans. We also used IQVIA National Prescription Audit data from Aug/2018 to Jul/2019 to estimate the number of prescriptions (Rx) dispensed and patient copayment for sacubitril/valsartan. Primary outcomes were proportion of plans requiring PA, frequency of specific PA criteria, number of sacubitril/valsartan Rx, and copayments. Data analysis was descriptive or used Chi-square.
Results: For Medicare, 27.7% of plans required PA for sacubitril/valsartan, a significantly lower rate than 57.2% for commercial plans (p<0.001). For both plans, most frequently required PA criteria were ejection fraction (71.6%, 90.9%) and NYHA class (60.4%, 90.8% for Medicare and commercial plans, respectively). There were 814,437 sacubitril/valsartan Rx dispensed over the year for Medicare and 822,292 for commercial plans. Based on estimated HFrEF populations for each plan type, 4-fold more sacubitril/valsartan Rx were dispensed in commercial than in Medicare plans (820 Rx vs. 215 Rx/1,000 HFrEF population). Copay amounts varied by plan type, with significantly more sacubitril/valsartan Rx having no patient copayment required in commercial (32.4%) than Medicare plans (19.3%) (p<0.001).
Conclusions: Despite commercial plans having greater PA requirements than Medicare, use of sacubitril/valsartan was higher in commercial plans. Thus, PA policies may not represent a major barrier to sacubitril/valsartan use. Given that commercial plans had more Rx with no or low copays than Medicare, copay amounts may be more influential on sacubitril/valsartan use.
