Heart Failure Guidelines Influence Medicare Drug Coverage Policies

Strategic Insights -

A recent study published in the Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease has found that guidelines issued by the American Heart Association/American College of Cardiology/Heart Failure Society of America have had a significant impact on Medicare drug coverage policies for two life-saving medications used to treat heart failure: angiotensin receptor neprilysin inhibitors (ARNI) and sodium glucose cotransporter-2 inhibitors (SGLT2i). The study used a quasi-experimental analysis to assess the effect of the guidelines on coverage barriers to these medications.

Key Takeaways:

  • The study found that prior to the publication of the guidelines, the majority of Medicare drug plans had coverage barriers to ARNI and SGLT2i, with monthly rates ranging from 94.3% to 97.4% for ARNI and 93.2% to 96.6% for SGLT2i.
  • Most barriers were due to tier 3 out-of-pocket cost-sharing requirements, which remained stable until October 2022.
  • The publication of the guidelines was associated with a 1-2 percentage point decline in coverage barriers for both ARNI and SGLT2i over a two-year period.
  • The study's findings suggest that robust strategies are needed to improve access to life-saving heart failure medications.
  • The American Heart Association/American College of Cardiology/Heart Failure Society of America added Value Statements to heart failure guidelines to promote better coverage for high-value therapies and inform policymakers about cost-effectiveness.

Statistics:

  • 94.3% to 97.4% of Medicare drug plans had coverage barriers to ARNI each month.
  • 93.2% to 96.6% of Medicare drug plans had coverage barriers to SGLT2i each month.
  • 1-2 percentage points decline in coverage barriers for both ARNI and SGLT2i over two years.
  • 7396 Medicare drug plans were analyzed in the study.
  • 2 life-saving medications used to treat heart failure were examined: ARNI and SGLT2i.

Sources:

  • Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease, 2025,14(20).
  • https://doi-org.sdpl.idm.oclc.org/10.1161/JAHA.125.043610.
  • American Heart Association.
  • American College of Cardiology.
  • Heart Failure Society of America.
  • Leon H. Charney Division of Cardiology, Department of Medicine NYU Grossman School of Medicine New York NY, United States.