Prescribing a Generic for CVD? Plan, Drug Type, and Condition Impact Availability

Coverage of key CVD medications in low-cost generic drug programs in the United States differs by plan, medication type, and condition, according to an analysis published recently online in Annals of Internal Medicine.

In broad strokes, availability of evidence-based drug classes was better for hypertension and hyperlipidemia therapies than it was for medications used in heart failure, atrial fibrillation (AF), and post-ACS secondary prevention, researchers led by Ivy Ton, PharmD (Western University of Health Sciences, Pomona, California), report.

“Furthermore, few programs carried multiple drugs within classes or multiple strengths, affecting drug choice and dose titratability,” they write, noting that each state in the country had at least three such programs available to help keep medication costs down for patients at the time of the analysis.

Senior author Cynthia Jackevicius, PharmD (Western University of Health Sciences), pointed out a couple of surprising findings—namely, the relative lack of coverage across plans for certain generic medications that are widely used and have been around for a long time, like ARBs and sublingual nitroglycerin.

Jackevicius told TCTMD that her team had anticipated that they’d see broader coverage of generic therapies for treating CVD that are backed by strong recommendations in guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA). “You’d expect that medications that are generic, [have] been around for a long time, [and] have several manufacturers . . . would be on these plans and they would be readily available at a lower cost,” said Jackevicius.

She led a prior study looking at access to statins in these low-cost generic programs that are aimed at making prescriptions more affordable for low-income and uninsured individuals, and had been interested in revisiting the topic in a more-comprehensive way incorporating a greater breadth of CVD therapies. The time was right for the new analysis, Jackevicius said, as there has been renewed interest in these programs in recent years spurred by the creation of Mark Cuban’s Cost Plus Drug Company and a continuing focus on the affordability of medications.

Many patients—and even many clinicians—don’t know about these programs, and there’s little information available about how well they cover various CVD medications, she said.

To find out, the investigators evaluated 19 low-cost generic programs in the US, examining formularies available in March and April 2023. One program (Cost Plus Drug Company) operated only online and was available nationwide. Another four (Costco, Kroger, Walmart, and Walgreens) were available in more than 40 states, and the rest were regional or state-specific.

There are a lot of medications that help patients with heart disease but if they can’t access them in an affordable way, we can’t treat heart disease optimally or prevent it. Cynthia Jackevicius

Ton et al evaluated coverage of key evidence-based drug classes—based on class I recommendations in ACC/AHA guidelines—for six CVD conditions: AF, heart failure, hyperlipidemia, hypertension, post-ACS secondary prevention, and stable angina. Their analysis included a look at the availability of drugs with the highest-quality evidence as well as the number of different options and dosages within drug classes.

In general, availability of medications varied across programs, drug type, and medical condition. Certain plans—including H-E-B, Kroger, Cost Plus Drug Company, and Walmart—provided a greater number of drug classes and more choices within those classes, whereas others had more-limited options.

The vast majority of programs covered ACE inhibitors, beta-blockers, loop diuretics, and thiazides (95% for all), as well as moderate-intensity statins (90%), with poorer availability for generics that are more expensive or used less often. For antiplatelets, only five of 19 programs offered clopidogrel, one offered prasugrel, and none offered ticagrelor. And although 63% of programs provided coverage for at least one class III antiarrhythmic, only 16% provided at least two different options within that category.

Coverage was generally good for hypertension and hyperlipidemia treatments, and more limited for other conditions. Only one program offered at least one medication in every key class for AF, for instance, and only five programs provided coverage for all important classes of generic heart failure drugs. For post-ACS secondary prevention, only four programs had all categories available.

When these programs provide limited options, it “can create disparities in pharmacoequity for socioeconomically disadvantaged patients,” the investigators write. That can lead to increased out-of-pocket costs and restricted availability to necessary medications, which in turn could worsen patient outcomes, they add.

“We hope that our study will shed light on this and bring up these areas where there can be improvements, where there are some potential gaps in coverage for common cardiovascular conditions, and have some of these programs reexamine what they’re covering and hopefully add some of these medications,” Jackevicius said.

The paper, and its supplementary appendix, also provides a resource for clinicians when they’re exploring ways to make medications more affordable for their patients, she said. There are details on each of the 19 programs examined as part of the study, with information on what medications are covered.

Many healthcare professionals may not think about asking patients about cost barriers, “so this can highlight the need to ask patients about this and then provide them with [information on low-cost generic programs] as another option,” Jackevicius said.

In a big-picture sense, “there are a lot of medications that help patients with heart disease but if they can’t access them in an affordable way, we can’t treat heart disease optimally or prevent it and prevent future events,” she said. “So we do need to look at multiple methods to try to address medication access and cost.”