Background: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.Methods: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.Results:Overall, 48.1% (1394/2896) of insurance plans required PA for sacubitril/valsartan. Fewer Medicare (27.7%) than commercial (57.2%) plans required PA (P<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%; P<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.Conclusions: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.

中文翻译：

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Sacubitril/Valsartan 在射血分数降低的心力衰竭患者的医疗保险和商业计划中的事先授权、共付额和使用

背景：据报道，在射血分数降低的心力衰竭患者中，沙库巴曲/缬沙坦的吸收缓慢，这可能会对临床结果产生负面影响。我们通过保险计划类型描述了预先授权 (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。方法：我们使用来自保险的 PA 数据进行了一项全国人口水平的横断面研究2019 年 3 月访问的覆盖范围网站和 2018 年 8 月至 2019 年 7 月的 IQVIA 国家处方审计数据。主要结果是需要 PA 的计划比例、特定 PA 标准的频率、沙库巴曲/缬沙坦处方的数量以及每种保险计划类型的共付额。结果：总体而言，48.1% (1394/2896) 的保险计划需要对沙库巴曲/缬沙坦进行 PA。更少的医疗保险（27。P <0.001)。对于这两种计划类型，最常要求的 PA 标准分别是医疗保险和商业计划的射血分数 (71.6%, 90.9%) 和纽约心脏协会等级 (60.4%, 90.8%)。共付额因计划类型而异，与 Medicare 计划（19.3%；P<0.001)。从 2018 年 8 月到 2019 年 7 月，共有 814,437 份用于医疗保险的沙库巴曲/缬沙坦处方和 822,292 份用于商业计划的处方。根据对每种计划类型的射血分数降低的心力衰竭人群的估计，分配的沙库巴曲/缬沙坦处方增加了 4 倍与医疗保险计划相比（820 对 215 个处方/1000 名射血分数降低的心力衰竭个体）。在医疗保险和商业计划人群中，使用沙库巴曲/缬沙坦处方的心力衰竭患者的估计比例为 3.6% (1.5%–6.8%) 和 13.7% (4.9%–31.8%)。结论：尽管商业计划具有更大的 PA与 Medicare 相比，sacubitril/缬沙坦的人群调整使用在商业计划中更高。鉴于商业计划比 Medicare 有更多的低共付额处方，共付额政策可能比其 PA 政策对 sacubitril/valsartan 使用的影响更大。两种计划类型中的低沙库巴曲/缬沙坦使用突出了药物使用不足的多因素性质，其中包括我们评估的药物政策之外的因素。