Navigating Formularies and Coverage for AFib Anticoagulant Therapy

In "Navigating Formularies and Coverage for AFib Anticoagulant Therapy," our expert describes the payer landscape that surrounds anticoagulant prescribing.

Dr. Barnes calls working with different formularies one of the biggest challenges for clinicians and their patients. There are many formularies, and they have changed considerably over the last several years. When DOACs first came out, many plans restricted access and wanted patients to stay on warfarin because of its lower cost.

Once it became clear that DOACs were superior medications, access through the formulary became easier. However, it often came with a much higher out-of-pocket cost for patients. Step therapy and prior authorization still arise in certain situations. For roughly the last 10 years, though, Dr. Barnes says clinicians can usually prescribe a DOAC and get it covered.

He notes that a formulary sometimes prefers one drug over another. He recalls a case a few years ago in which a major insurer chose to preferentially cover one of the drugs. That created havoc for patients already taking a different DOAC.

Having to switch exposed those patients to risk, and it caused a lot of confusion. Advocacy rose from both the patient population and clinicians. Thankfully, the insurer reversed course. It returned to offering the two most commonly used DOACs, apixaban and rivaroxaban, on equal footing, and that restored a steady state.

Dr. Barnes says clinicians continue to monitor the situation. Some DOACs will go generic before others, so formularies will likely keep changing. His team must respond to ensure each patient gets the best anticoagulant for them in a way that is affordable.

He acknowledges that this takes a lot of work. His office puts substantial time and resources into navigating coverage. They do it, he says, because it is the right thing for the patient.

Up next, in "Choosing an Anticoagulant in AFib: Shared Decision-Making and Affordability," our expert explains how he weighs these factors with patients in the exam room.