Medicare Coverage and Out-of-Pocket Costs of Quadruple Drug Therapy for Heart Failure

J Am Coll Cardiol. 2022 Jun 28;79(25):2516-2525. doi: 10.1016/j.jacc.2022.04.031.


Background: Beta-blockers, angiotensin receptor-neprilysin inhibitor (ARNI), mineralocorticoid receptor antagonists, and sodium-glucose cotransporter-2 inhibitors (SGLT2i), known as quadruple therapy, are recommended for patients with heart failure with reduced ejection fraction (HFrEF).

Objectives: This study sought to determine Medicare coverage and out-of-pocket (OOP) costs of quadruple therapy and regimens excluding ARNI or SGLT2i.

Methods: This study assessed cost sharing, prior authorization, and step therapy in all 4,068 Medicare prescription drug plans in 2020. OOP costs were determined during the standard coverage period and annually based on the Medicare Part D standard benefit, inclusive of deductible, standard coverage, coverage gap, and catastrophic coverage.

Results: Tier ≥3 cost sharing was required by 99.1% of plans for ARNI and 98.5% for at least 1 SGLT2i. Only ARNI required prior authorization (24.3% of plans), and step therapy was required only for SGLT2is (5.4%) and eplerenone (0.8%). The median 30-day standard coverage OOP cost of quadruple therapy was $94 (IQR: $84-$100), including $47 (IQR: $40-$47) for ARNI and $45 (IQR: $40-$47) for SGLT2i. The median annual OOP cost of quadruple therapy was $2,217 (IQR: $1,956-$2,579) compared with $1,319 (IQR: $1,067-$1,675) when excluding SGLT2i and $1,322 (IQR: $1,025-$1,588) when including SGLT2i and substituting an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker for ARNI. The median 30-day OOP cost of generic regimens was $3 (IQR: $0-$9).

Conclusions: Medicare drug plans restrict coverage of quadruple therapy through cost sharing, with OOP costs that are substantially higher than generic regimens. Quadruple therapy may be unaffordable for many Medicare patients with HFrEF unless medication prices and cost sharing are reduced.

Keywords: Medicare; drug costs; health insurance; heart failure.

MeSH terms

  • Aged
  • Angiotensin Receptor Antagonists / therapeutic use
  • Diabetes Mellitus, Type 2*
  • Drug Costs
  • Drugs, Generic
  • Health Expenditures
  • Heart Failure* / drug therapy
  • Humans
  • Medicare Part D*
  • Sodium-Glucose Transporter 2 Inhibitors* / therapeutic use
  • Stroke Volume
  • United States


  • Angiotensin Receptor Antagonists
  • Drugs, Generic
  • Sodium-Glucose Transporter 2 Inhibitors