OBJECTIVES:  In chronic heart failure (CHF) the standard of care is comprised of inexpensive evidence-based generic agents. Novel CHF therapies sacubitril/valsartan and ivabradine offer improvements in clinical outcomes and are attractive treatment options for patients who continue to suffer from high mortality and morbidity rates. However, in a highly-genericized CHF market, prescribing of these therapies could result in significantly increased expenditures in an environment of tightening healthcare budgets for U.S. insurers. This research explores how payers and physicians interact and how reimbursement decisions impact the prescribing of novel CHF therapies. METHODS:  In September 2016, 72 cardiologists and 71 primary care physicians across the U.S. were surveyed regarding their current prescribing of sacubitril/valsartan and ivabradine. Thirty U.S. managed care organization pharmacy and medical directors were also surveyed. RESULTS:  Despite being viewed as more efficacious than standard of care CHF therapies by surveyed cardiologists, sacubitril/valsartan is being prescribed to only a fraction of CHF patients. Cost-related issues, unfavorable payer coverage, and restrictions set by payers are major barriers to prescribing of sacubitril/valsartan and ivabradine by surveyed physicians. For 35-45% of physicians, payer-imposed restrictions have contributed to them not prescribing these drugs to eligible patients. Meanwhile, cost drives formulary inclusion decisions for 47% of surveyed payers, who impose significant access and reimbursement restrictions on sacubitril/valsartan and ivabradine. Prior authorization is the main cost-containment strategy, employed by over 50% of surveyed payers. One strategy being explored to overcome the barriers to drug access is engagement in outcomes-based contracts, whereby payers reward good outcomes through improved formulary placement of the drug or a credit toward rebates given. CONCLUSIONS:  In a highly-genericized CHF market, health plans provide less-favorable coverage and reimbursement for the premium-priced therapies. Engaging in OBC may be one way forward for manufacturers to get better coverage of their drugs and demonstrate their cost-effectiveness.