For a study, researchers sought to establish Medicare coverage and out-of-pocket (OOP) expenditures for quadruple treatment and regimens that did not include angiotensin receptor-neprilysin inhibitor (ARNI) or SGLT2i.

In 2020, all 4,068 Medicare prescription medication plans were evaluated for cost-sharing, prior authorization, and step therapy. During the regular coverage period and yearly, OOP expenses were calculated using the Medicare Part D standard benefit, which included the deductible, standard coverage, coverage gap, and catastrophic coverage.

Tier ≥3 cost-sharing was required by 99.1% of ARNI plans and 98.5% of SGLT2i plans. Prior authorization was necessary only for ARNI (24.3% of plans), and step treatment was required only for SGLT2is (5.4%) and eplerenone (0.8%). The median 30-day standard coverage OOP cost of quadruple treatment was $94 (IQR: $84-$100), with ARNI costing $47 (IQR: $40-$47) and SGLT2i costing $45 (IQR: $40-$47). When excluding SGLT2i and substituting an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker for ARNI, the median annual OOP cost of quadruple therapy was $2,217 (IQR: $1,956-$2,579). When including SGLT2i and substituting an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker for ARNI, the median annual OOP cost was $1,322 (IQR: $1,025-$1,588). The median OOP cost of generic regimens was $3 (IQR: $0-$9) for 30 days.

Medicare prescription programs limit triple therapy coverage through cost-sharing, with OOP prices that are much higher than generic regimens. As a result, many Medicare patients with HFrEF may find quadruple treatment costly unless drug prices and cost-sharing decrease.

Reference: jacc.org/doi/10.1016/j.jacc.2022.04.031