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Prescription Drug Coverage of Guideline-Directed Medical Therapy for People Living with Heart Failure with Reduced
Simone S Cowan1, Lynette Kosar2, Stephanie Poon3
1Division of Cardiology, Department of Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.
Insights
Guideline-directed medical therapy (GDMT) for heart failure (HF) is under-prescribed in Canada due to inconsistent formulary access. Reimbursement criteria vary significantly across provinces, hindering evidence-based treatment for over 750,000 Canadians with HF.
Area of Science:
- Cardiology
- Pharmacoeconomics
- Health Policy
Background:
- Guideline-directed medical therapy (GDMT) for heart failure (HF) significantly reduces morbidity and mortality but is under-prescribed.
- Assessing formulary access to GDMT across Canada is crucial to identify barriers to evidence-based care.
Purpose of the Study:
- To evaluate formulary access and reimbursement differences for key GDMT medications across Canadian provinces, territories, and federal programs.
- To compare current coverage policies with evidence-based guidelines for heart failure management.
Main Methods:
- An environmental scan of formulary coverage for specific GDMT drug classes (ARNI, beta-blockers, SGLT2i, MRA, SNI) was conducted from June 2022 to July 2024.
- Data were collected for 10 Canadian provinces, 2 territories, and 6 federal programs.
Main Results:
- Significant provincial and territorial variations exist in GDMT coverage, particularly for sacubitril-valsartan and carvedilol.
- Universal coverage is noted for bisoprolol and spironolactone, while eplerenone and dapagliflozin have some restrictions.
- Prior medication use and prescriber qualifications are common reimbursement criteria, often not aligned with guidelines.
Conclusions:
- Disparities in drug reimbursement criteria create unequal access to GDMT for heart failure patients in Canada.
- Systemic changes in drug reimbursement funding are necessary to improve access to guideline-recommended therapies for the >750,000 Canadians living with HF.
Background:
Guideline-directed medical therapy (GDMT) for heart failure (HF) is cost-effective and is associated with significant reductions in morbidity and mortality. Yet, GDMT remains under-prescribed. The Canadian Cardiovascular Society's HF Working Group assessed formulary access to GDMT across Canada to identify differences in reimbursement and review how coverage aligns with evidence-based guidelines.
Methods:
An environmental scan was conducted for the period from June 2022 to July 2024 on the formulary coverage of angiotensin receptor-neprilysin inhibitors, beta-blockers, sodium-glucose cotransporter-2 inhibitors, mineralocorticoid receptor antagonists, and sinus node inhibitors in 10 Canadian provinces, 2 territories, and 6 federal programs.
Results:
In all provincial and territorial plans, patient eligibility and prior medication use criteria are required for sacubitril-valsartan reimbursement. Sacubitril-valsartan has coverage restrictions based on natriuretic peptides and prescriber qualifications, except in Ontario and Quebec. Carvedilol coverage is not a benefit in Ontario or British Columbia. Bisoprolol and spironolactone have universal coverage. Eplerenone is not listed in British Columbia. Dapagliflozin coverage is a benefit in all plans except Quebec. Ivabradine coverage has patient eligibility and prior medication use criteria in all provinces and territories and prescriber restrictions in certain regions. Two federal plans have universal coverage of GDMT.
Conclusions:
Differences in criteria for drug reimbursement create provincial and territorial variation in access to GDMT in Canada. Coverage criteria include prior medication use and prescriber qualifications, which are not supported by evidence-based guidelines. Systemwide changes in the funding of drug reimbursement programs are needed to improve access to GDMT for the more than 750,000 people living with HF in Canada.
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