Tips for Navigating Prior Authorization and Out-of-Pocket Costs for HFrEF Medications

Larry A. Allen, MD, MHS; Sarah J. Sarni, BSN, BA


May 11, 2021

Editorial Collaboration

Medscape &

As clinicians, we know the importance of promptly initiating treatment for our patients with heart failure with reduced ejection fraction (HFrEF) to improve survival, rehospitalization, and medication adherence. Several generic drug combination therapies are available to increase patient access and treatment. Such cost-effective regimens include angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, or mineralocorticoid receptor antagonists with loop diuretics, with or without the addition of digoxin. Moreover, in the past decade, a series of large randomized trials have shown the efficacy of newer classes of medications in improving health outcomes of patients with HFrEF. These newer medications include the I f inhibitor ivabradine (SHiFT study); the angiotensin receptor-neprilysin inhibitor (ARNI) sacubitril-valsartan (PARADIGM-HF and PIONEER-HF trials); the sodium-glucose transporter 2 (SGLT2) inhibitors dapagliflozin (DAPA-HF study) and empagliflozin (EMPEROR-Reduced trial); and the soluble guanylate cyclase activator vericiguat (VICTORIA trial).

Although these new treatment options for HFrEF are proven to be safe and well tolerated across a wide range of patients, there are obstacles to their widespread use — namely, the high cost of these drugs, prior authorization requirements, and out-of-pocket fees. Not only must patients often first obtain approval from their insurance companies for these prescriptions, but they are also required to pay greater out-of-pocket costs for them than generic drugs. Perhaps not surprisingly, the use of generic ACE inhibitors and beta-blockers for HFrEF remains high, whereas uptake of ivabradine and sacubitril-valsartan continues to be slow and SGLT2 inhibitors are only just beginning to be prescribed.

Although clinicians might sometimes prefer to avoid cost discussions with patients, health insurance coverage of medications and out-of-pocket costs are clearly relevant to patient burden and adherence and therefore must be addressed. Furthermore, in one recent study, patients expressed a strong desire to have open and honest discussions with their clinicians about the benefits and cost of treatment.

In addition to working through the preauthorization process required for newer drugs for HFrEF, patients have other, often significant, cost considerations. Because the average patient with HFrEF has three or more comorbid conditions and takes 10 or more medications, they must also take into account the cost of other expensive medications, such as direct oral anticoagulants for atrial fibrillation and additional lipid-lowering therapy for high-risk cardiovascular disease. These cumulative treatment expenses can become overly burdensome and create an additional barrier to care — underscoring the importance of proactive management on the part of the clinician.

By understanding the prior authorization process, discussing cost considerations with patients, utilizing online tools, and recommending resources to help our patients determine out-of-pockets costs, clinicians can better navigate this process — in turn enhancing the care and management of patients.


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