Sacubitril/valsartan can be considered a cost-effective treatment at a daily price of €5.25. Unless priced lower than enalapril (<€0.045 per day), sacubitril/valsartan is very unlikely to be cost-saving/dominant.

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Using the German HTA guidelines, the ICER is not taken into consideration. Instead, the efficiency frontier was introduced as an alternative, to avoid the use of QALYs and the setting of willingness-to-pay thresholds. • We conducted the first direct comparison of the German efficiency frontier methodology to the conventional ICER, using sacubitril/valsartan, a new treatment for patients with chronic heart failure with a reduced ejection fraction. • Sacubitril/valsartan has a favourable ICER in the German setting, comparable to other European countries. However, using the efficiency frontier, the results would inform decision makers that a considerable discount needs to be negotiated.