Department of Pharmacy Practice and Administration, Western University of Health Sciences, Pomona, CA (A.F.O., T.T.T., Q.T.L., M.Y., C.A.J.).
Department of Pharmacy, Veterans Affairs Greater Los Angeles Healthcare System, CA (A.F.O., C.A.J.).
Circ Cardiovasc Qual Outcomes. 2021 Sep;14(9):e007665. doi: 10.1161/CIRCOUTCOMES.120.007665. Epub 2021 Sep 1.
Slow uptake of sacubitril/valsartan in patients with heart failure with reduced ejection fraction has been reported, which may negatively impact clinical outcomes. We characterized prior authorization (PA) burden, prescription copayment, and utilization of sacubitril/valsartan by insurance plan type to identify potential barriers to its use.
We 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. Primary outcomes were proportion of plans requiring PA, frequency of specific PA criteria, number of sacubitril/valsartan prescriptions, and copayments per insurance plan type.
Overall, 48.1% (1394/2896) of insurance plans required PA for sacubitril/valsartan. Fewer Medicare (27.7%) than commercial (57.2%) plans required PA (<0.001). 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. Copayment amounts varied by plan type, with more sacubitril/valsartan prescriptions for commercial plans not requiring a patient copayment (32.4%) compared with Medicare plans (19.3%; <0.001). There were 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/1000 individuals in the heart failure with reduced ejection fraction population). The estimated proportion of heart failure with reduced ejection fraction patients prescribed sacubitril/valsartan was 3.6% (1.5%-6.8%) for Medicare and 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. 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.
据报道，射血分数降低的心力衰竭患者对沙库巴曲缬沙坦的接受度较低，这可能对临床结局产生负面影响。我们描述了按保险计划类型划分的预先授权（PA）负担、处方共付额和沙库巴曲缬沙坦的使用情况，以确定其使用的潜在障碍。
我们使用 2019 年 3 月从保险覆盖网站获取的 PA 数据和 2018 年 8 月至 2019 年 7 月 IQVIA 全国处方审计数据，开展了一项全国性的基于人群的横断面研究。主要结局指标为需要 PA 的计划比例、特定 PA 标准的出现频率、沙库巴曲缬沙坦处方数量以及每种保险计划类型的共付额。
总体而言，48.1%（1394/2896）的保险计划需要 PA 才能获得沙库巴曲缬沙坦。与商业保险计划（57.2%）相比，医疗保险计划（27.7%）需要 PA 的比例更低（<0.001）。对于这两种计划类型，最常需要的 PA 标准是射血分数（分别为 71.6%和 90.9%）和纽约心脏协会分级（分别为 60.4%和 90.8%）。共付额因计划类型而异，对于不需要患者共付额的商业保险计划，沙库巴曲缬沙坦的处方量更多（32.4%），而对于医疗保险计划则更少（19.3%；<0.001）。从 2018 年 8 月至 2019 年 7 月，医疗保险计划开出了 814 437 份沙库巴曲缬沙坦处方，商业保险计划开出了 822 292 份。根据每种计划类型的射血分数降低的心力衰竭估计人群，商业保险计划开出的沙库巴曲缬沙坦处方数量是医疗保险计划的 4 倍（心力衰竭射血分数降低人群中开出的处方数量分别为每 1000 人 820 份和 215 份）。估计使用沙库巴曲缬沙坦的射血分数降低的心力衰竭患者比例为医疗保险计划 3.6%（1.5%-6.8%），商业保险计划 13.7%（4.9%-31.8%）。
尽管商业保险计划的 PA 要求高于医疗保险计划，但商业保险计划中沙库巴曲缬沙坦的人群调整使用率更高。鉴于商业保险计划开出的低共付额处方数量多于医疗保险计划，共付额政策可能比 PA 政策对沙库巴曲缬沙坦的使用更有影响。两种计划类型中沙库巴曲缬沙坦的使用率均较低，这突出表明药物利用率不足是多因素的，包括我们评估的药物政策以外的因素。
