The chronic heart failure therapy market is crowded and dominated by generics. In 2015 in the United States, the first new branded agents in more than 15 years entered that market. Using primary research from U.S. cardiologists, primary care physicians, and managed care organization medical/pharmacy directors, this content examines market access factors in the United States. Understanding the interaction between payers and physicians, including the impact of reimbursement decisions on the prescribing and uptake of therapies at the brand level, will help unravel treatment drivers in this indication.

Table of contents

  • Heart Failure - Access & Reimbursement - Detailed, Expanded Analysis Chronic Heart Failure (US)
    • Actionable Recommendations to Optimize Market Access
      • Successes and Stumbles
        • Successes Among Chronic Heart Failure Therapies in the United States
        • Stumbles Among Chronic Heart Failure Therapies in the United States
        • United States: Reimbursement Successes and Stumbles
        • Key Stakeholders in the Road to Market Access
          • United States: Stakeholder Dynamics in the Road to Reimbursement
        • Key Market Access Roadblocks
          • Reimbursement Dynamics
            • United States: Commercial Managed Care Organizations
              • Lessons Learned and Key Takeaways
              • Drivers of Reimbursement by MCOs for CHF on Commercial Plans
              • Importance of Drug Attributes for Formulary Inclusion
              • Importance of Efficacy Attributes
              • Most Compelling Pharmacoeconomic Outcomes Data
              • Drivers
              • Key Findings
              • Most Common Restrictions Used in Commercial Plans
              • Most Common Restrictions Used in Medicare Plans
              • Prior Authorization
              • Conditions Required in Prior Authorization Process in Commercial Plans
              • Conditions Required in Prior Authorization Process in Medicare Plans
              • Restrictions Used in Commercial Plans to Manage Utilization of Entresto and Corlanor
              • Restrictions Used in Medicare Plans to Manage Utilization of Entresto and Corlanor
          • Pricing and Reimbursement, Policy, and Coverage: Impact on Prescribing
            • Patient Share in Commercial Plans
              • Key Findings
              • Patient Share for CHF Among Commercially Insured Patients: HFrEF
              • Patient Share for CHF Among Commercially Insured Patients: HFpEF
              • Market Access Issues That Restrict Prescribing of Entresto
              • Market Access Issues That Restrict Prescribing of Corlanor
              • Top Prescribing Drivers
              • Most Influential Factors on Choosing Chronic Heart Failure Therapy
              • Most Influential Clinical Factors on Choosing Chronic Heart Failure Therapy
              • Most Influential Non-Clinical Factors on Choosing Chronic Heart Failure Therapy
            • Prescriber Preference
              • Prescriber Preferences for Chronic Heart Failure
              • HFrEF Agents Prescribed to Commercially Insured Patients by Line of Treatment: Cardiologists
              • HFrEF Agents Prescribed to Commercially Insured Patients by Line of Treatment: Primary Care Physicians
              • HFrEF Agents Preferred for Commercially Insured Patients by Line of Treatment: Cardiologists
              • HFrEF Agents Preferred for Commercially Insured Patients by Line of Treatment: Primary Care Physicians
              • HFpEF Agents Prescribed to Commercially Insured Patients by Line of Treatment: Cardiologists
              • HFpEF Agents Prescribed to Commercially Insured Patients by Line of Treatment: Primary Care Physicians
              • HFpEF Agents Preferred for Commercially Insured Patients by Line of Treatment: Cardiologists
              • HFpEF Agents Preferred for Commercially Insured Patients by Line of Treatment: Primary Care Physicians
            • Impact of Payer Policy on Prescribing
              • Key Findings
              • Physician-Reported Most Important Cost Restrictions Imposed on Entresto
              • Physician-Reported Most Important Cost Restrictions Imposed on Corlanor
              • Key Restrictions That Constrain Prescribing of CHF Agents: Cardiologists
              • Key Restrictions That Constrain Prescribing of CHF Agents: Primary Care Physicians
              • Key Levers and Constraints on Current Therapies: Role of Key Restrictions
          • Market Access Landscape for Emerging Therapies
            • Likely Impact of Emerging Therapy
              • Likely Impact of Emerging Therapies for Chronic Heart Failure
              • Patient Share for HFrEF Therapies if Emerging Agents Are on Preferred vs. Nonpreferred Tier: Cardiologists
              • Patient Share for HFrEF Therapies if Emerging Agents Are on Preferred vs. Nonpreferred Tier: Primary Care Physicians
              • Patient Share for HFpEF Therapies if Emerging Agents Are on Preferred vs. Nonpreferred Tier: Cardiologists
              • Patient Share for HFpEF Therapies if Emerging Agents Are on Preferred vs. Nonpreferred Tier: Primary Care Physicians
            • Potential Placement of Emerging Therapy at Various Prices
              • Potential Reimbursement of Emerging Therapies for Chronic Heart Failure
              • Potential Formulary Placement of Entresto Post-Launch for HFpEF
              • Potential Formulary Placement of Xarelto at Various Price Points
              • Utilization Management Approaches Expected for Entresto in HFpEF
            • Prescriber and MCO Opinion on Remaining Unmet Need
              • Key Findings
              • Current Level of Unmet Need for Additional Pharmacological Agents in HFrEF and HFpEF: Physicians
              • Mean R&D Spending by Physicians
              • Current Level of Unmet Need for Additional Pharmacological Agents in CHF: MCOs
              • Current Level of Unmet Need for Additional Pharmacological Agents in HFrEF and HFpEF: MCOs
              • Mean R&D Spending by MCOs
          • Methodology
            • Abbreviations
            • Primary Market Research Methodology: Physicians
              • Physician Specialty
              • Years in Practice Post-Residency
              • Average Number of Chronic Heart Failure Patients Under Management per Year
              • Percentage of CHF Patients with Preserved or Reduced Ejection Fraction Under Management
              • Region of Practice Location
              • State of Practice Location
              • Insurance Coverage of Chronic Heart Failure Patients
              • Physician Practice Setting
            • Primary Market Research Methodology: MCOs
              • Position Held at MCO
              • Region of MCO Location
              • State of MCO Location
              • Operations of MCO
              • Types of Health Plans Offered
              • Number of Covered Lives
              • Average Number of Individual Lives Covered
              • Number of MCO P&T Committee Members
              • Frequency of P&T Committee Meetings
              • Type of Formulary Used in Commercial Plans
          • Appendix
            • Physician Survey
              • Physician Prescribing Experience with Chronic Heart Failure Drug Classes
              • Physician Familiarity with Entresto and Corlanor
              • Percentage of CHF Patients with Reduced or Preserved Ejection Fraction by NYHA Class
              • Treatment Rates of CHF Patients with Reduced or Preserved Ejection Fraction by NYHA Class: Cardiologists
              • Treatment Rates of CHF Patients with Reduced or Preserved Ejection Fraction by NYHA Class: Primary Care Physicians
              • Drug Classes Prescribed to Treat Comorbidities
              • Percentage of Chronic Heart Failure Patients on Each Line of Treatment by NYHA Class
              • Use of Combination Therapy in Chronic Heart Failure by Line of Treatment
              • Most Common Reasons for CHF Therapy Discontinuation: Cardiologists
              • Most Common Reasons for CHF Therapy Discontinuation: Primary Care Physicians
              • Treatment Characteristics for Chronic Heart Failure Drugs/Drug Classes
              • Reasons for Not Prescribing CHF Drugs/Drug Classes: Cardiologists
              • Reasons for Not Prescribing CHF Drugs/Drug Classes: Primary Care Physicians
              • Percentage of CHF Patients Who Discontinued Treatment with Entresto or Corlanor
              • Effect of the New Heart Failure Treatment Guidelines on Access to Entresto and Corlanor
              • Perceived Performance of CHF Therapies Across Clinical and Non-Clinical Attributes: Physicians
              • Changes in Overall Use of Drugs/Drug Classes Over the Past Year in CHF Patients
              • Reasons for Increased Use of CHF Drugs/Drug Classes in the Past Year: Cardiologists
              • Reasons for Increased Use of CHF Drugs/Drug Classes in the Past Year: Cardiologists (Cont.)
              • Reasons for Increased Use of CHF Drugs/Drug Classes in the Past Year: Primary Care Physicians (Cont.)
              • Reasons for Increased Use of CHF Drugs/Drug Classes in the Past Year: Primary Care Physicians
              • Reasons for Decreased Use of CHF Drugs/Drug Classes in the Past Year: Cardiologists (Cont.)
              • Reasons for Decreased Use of CHF Drugs/Drug Classes in the Past Year: Cardiologists
              • Reasons for Decreased Use of CHF Drugs/Drug Classes in the Past Year: Primary Care Physicians (Cont.)
              • Reasons for Decreased Use of CHF Drugs/Drug Classes in the Past Year: Primary Care Physicians
              • Physician Views on Entresto
              • Physician Views on Corlanor
              • 2015 and Anticipated 2016 Treatment Rates for Entresto and Corlanor
              • Factors Driving Prescribing of Entresto
              • Factors Constraining Prescribing of Entresto
              • Factors Driving Prescribing of Corlanor
              • Factors Constraining Prescribing of Corlanor
              • Preferred Comparator for an Emerging Chronic Heart Failure Agent
              • Level of Promise to Fulfill Unmet Need in Chronic Heart Failure for Entresto and Xarelto: Physicians
              • Main Reasons for Anticipated Prescribing of Entresto for HFpEF
              • Main Reasons for Anticipated Prescribing of Xarelto for HFrEF
              • Future Effects of Availability of Entresto for HFpEF on Its Prescribing for HFrEF
              • Anticipated Prescribing of CHF Drugs/Drug Classes for HFrEF by 2020: Cardiologists
              • Anticipated Prescribing of CHF Drugs/Drug Classes for HFrEF by 2020: Primary Care Physicians
              • Anticipated Prescribing of CHF Drugs/Drug Classes for HFpEF by 2020: Cardiologists
              • Anticipated Prescribing of CHF Drugs/Drug Classes for HFpEF by 2020: Primary Care Physicians
              • Level of Promise for Stem Cell and Gene Therapies as Treatment Options in CHF: Physicians
            • MCO Survey
              • Members of P&T Committee with the Greatest Influence on Formulary Decisions for Heart Failure Drugs
              • Items Needed for Inclusion in a Chronic Heart Failure Drug Review by P&T Committee
              • Preferred Comparator for an Emerging Chronic Heart Failure Therapy
              • MCO General Impression of Entresto and Corlanor
              • Coverage Status of Key Chronic Heart Failure Therapies Included on Commercial Plans
              • Expected Coverage Status for Key CHF Therapies Included on Commercial Plans 12 Months from Now
              • Most Common Coinsurance for Drugs Covered Under the Pharmacy Benefit on Commercial Plans
              • Most Common Copayment for Drugs Covered Under the Pharmacy Benefit on Commercial Plans
              • Reimbursement Tier for Entresto and Corlanor on Commercial Plans
              • Number of Steps in Step Therapy for Entresto and Corlanor in Commercial Plans
              • Effect of Updated Guidelines on Utilization Management Approaches for Entresto and Corlanor
              • Coverage Status of Key Chronic Heart Failure Therapies Included on Medicare Plans
              • Expected Coverage Status for Key CHF Therapies Included on Largest Medicare Advantage Plans 12 Months from Now
              • Most Common Coinsurance for Drugs Covered Under the Pharmacy Benefit on Medicare Plans
              • Most Common Copayment for Drugs Covered Under the Pharmacy Benefit on Medicare Plans
              • Reimbursement Tier for Entresto and Corlanor on Medicare Plans
              • Number of Steps in Step Therapy for Entresto and Corlanor in Medicare Plans
              • Level of Promise to Fulfill Unmet Need in CHF for Entresto and Xarelto: MCOs
              • Number of Steps in Step Therapy Expected for Entresto in HFpEF
              • Current Coverage Status of Xarelto on Formularies of Commercial Plans
              • Utilization Management Approaches Expected for Xarelto in HFrEF
              • Number of Steps in Step Therapy Expected for Xarelto in HFrEF
              • Level of Promise for Stem Cell and Gene Therapies as Treatment Options in CHF: MCOs
              • Influence of Stem Cell Therapy Attributes on Their Potential Formulary Positioning
              • Effect of Drug's Prior Approval for Other Indications on Formulary Positioning When Launched for CHF
              • Influence of Drug's Prior Approval for Related Indications on their Formulary Positioning When Launched in CHF
              • Perceived Performance of CHF Therapies Across Clinical and Non-Clinical Attributes: MCOs
              • Percentage of MCOs Who Received Pharmacoeconomic/Health Economic Outcomes Data Supporting Entresto or Corlanor
              • Quality of Pharmacoeconomic/Health Economic Outcomes Data Supporting Entresto or Corlanor Submitted to MCOs
              • Impact of Pharmacoeconomics/Health Economic Outcomes Data on Utilization Management Approaches for Entresto and Corlanor

        Author(s): Dominika Rudnicka-Noulin, PhD, MSc

        Dominika Rudnicka-Noulin, PhD, MSc is a senior business insights analyst in the Cardiovascular, Metabolic and Renal division at Decision Resources Group, specializing in cardiovascular diseases, with expertise in heart failure and acute coronary syndrome.

        Prior to joining DRG, Dominika held a position of an associate editor at Nature Communications, working across a variety of therapy areas. Dominika also worked for three years as a Postdoctoral Research Associate on a joint project between Imperial College London and MedImmune aimed at developing more potent antibody-based drugs. Dominika gained her PhD at the Institut Pasteur in Paris, France where her work was funded by the European Commission Marie Skłodowska-Curie Actions


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