By Counterforce Health Team in Entresto (sacubitril/valsartan) —

Do You Qualify for Entresto (sacubitril/valsartan) Coverage by Humana in Virginia? Complete Decision Tree & Appeals Guide

Answer Box: Getting Entresto Covered by Humana in Virginia

Eligibility: You likely qualify if you have chronic heart failure with LVEF ≤40%, documented ACE inhibitor/ARB trial or intolerance, and NYHA Class II-IV symptoms. Fastest path: Submit prior authorization with recent echocardiogram, medication history, and cardiologist letter via Humana portal. First step today: Contact your cardiologist to request LVEF documentation and gather your ACE inhibitor/ARB trial records. Appeals deadline: 65 days from denial in Virginia.

Table of Contents

How to Use This Guide

This decision tree helps Virginia patients and clinicians navigate Humana's prior authorization requirements for Entresto (sacubitril/valsartan). Work through each section based on your current situation. If you're unsure about any medical details, consult your cardiologist before proceeding.

Key Virginia advantage: The state provides robust external review rights through the Bureau of Insurance if internal appeals fail, with expedited options for urgent cases.

Eligibility Triage: Do You Qualify?

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all plans Humana formulary Humana Drug Lists
Formulary Tier Tier 3 (brand) Plan documents Medicare Formulary
Step Therapy ACE inhibitor/ARB trial required PA criteria CMS Part D Guidelines
Quantity Limits 60 tablets per 30 days Plan policy Humana Provider Portal
Prescriber Cardiologist preferred PA form Humana PA Forms

Quick Eligibility Check

Answer these questions to determine your path:

  1. Do you have a confirmed heart failure diagnosis?
  2. Have you tried an ACE inhibitor or ARB?
  3. Do you have NYHA Class II-IV symptoms?

If "Likely Eligible": Document Checklist

You have a strong case for approval. Gather these documents before submitting:

Required Documentation

  • Recent echocardiogram (within 6 months) showing LVEF ≤40%
  • Heart failure diagnosis with ICD-10 code (typically I50.22 for chronic systolic HF)
  • NYHA Class documentation (II, III, or IV)
  • ACE inhibitor/ARB trial history with specific drugs, doses, dates, and outcomes
  • Current medications and dosing
  • Recent lab work (creatinine, potassium)
  • Cardiologist letter of medical necessity

Submission Path: Fastest Route to Approval

  1. Contact your cardiologist to request a medical necessity letter
  2. Gather all documentation using the checklist above
  3. Submit via Humana provider portal or fax (verify current submission method with Humana)
  4. Follow up within 72 hours to confirm receipt
  5. Expect decision within 72 hours (standard) or 24 hours (expedited)
  6. If approved, prescription will be processed normally
  7. If denied, proceed to appeals process
Tip: For patients with urgent symptoms, request expedited review when submitting. Humana must respond within 24 hours for expedited requests.

If "Possibly Eligible": Tests to Request

You may qualify but need additional documentation. Request these from your healthcare team:

Missing Documentation to Obtain

  • Echocardiogram or cardiac MRI if LVEF is unknown or outdated
  • Formal NYHA Class assessment from your cardiologist
  • Complete medication history with trial details for ACE inhibitors/ARBs
  • Specialist consultation if not currently seeing a cardiologist

Timeline for Re-application

  • Echocardiogram results: 1-2 weeks
  • Specialist appointment: 2-4 weeks in Virginia (verify with the source linked below)
  • Documentation compilation: 1 week
  • Resubmission: Once all documents are complete

Track your progress and reapply once you have complete documentation.

If "Not Yet": Alternatives to Discuss

If you don't currently meet criteria, discuss these options with your cardiologist:

Formulary Alternatives

Medication Class Examples Typical Coverage Notes
ACE Inhibitors Lisinopril, enalapril Tier 1 (generic) First-line therapy
ARBs Valsartan, losartan Tier 1-2 If ACE inhibitor not tolerated
Beta Blockers Carvedilol, metoprolol Tier 1 (generic) Standard heart failure therapy
SGLT2 Inhibitors Farxiga, Jardiance Tier 3 (may require PA) Newer heart failure indication

Preparing for Future Exception Requests

  • Document treatment failures with current medications
  • Track symptoms and hospitalizations
  • Maintain regular cardiology follow-up
  • Consider clinical trial participation if available in Virginia

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters and crafting targeted, evidence-backed responses. Their platform helps patients and clinicians navigate complex prior authorization requirements with payer-specific workflows and documentation templates.

If Denied: Virginia Appeals Process

Virginia provides strong consumer protections for insurance appeals. Here's your step-by-step path:

Internal Appeal (Redetermination)

Deadline: 65 days from denial notice Timeline: Humana must decide within 7 days (72 hours if expedited)

  1. File via Humana member portal or submit Request for Redetermination form
  2. Include medical necessity letter addressing specific denial reasons
  3. Attach all supporting documentation
  4. Request expedited review if health is at risk

Virginia External Review

If internal appeal fails, Virginia's Bureau of Insurance provides independent review.

Deadline: 120 days from final internal denial Timeline: 45 days for standard review, 72 hours for expedited Cost: Free

Process:

  1. Contact Bureau of Insurance at 1-877-310-6560 for guidance
  2. Submit Form 216-A (External Review Request)
  3. Include all appeal documentation
  4. Bureau assigns Independent Review Organization
  5. IRO decision is binding on Humana
Virginia Advantage: The state allows expedited external review for cancer and other urgent cases without exhausting internal appeals first.

Clinician Corner: Medical Necessity Letter

Essential Elements for Approval

Patient Information

  • Name, DOB, Humana member ID
  • Primary diagnosis with ICD-10 code
  • Current NYHA functional class

Clinical Justification

  • Recent LVEF measurement and date
  • Specific ACE inhibitor/ARB trials with outcomes
  • Current heart failure medications and response
  • Hospitalizations or emergency visits related to heart failure

Medical Necessity Statement

Sample Template Opening

"I am requesting prior authorization for Entresto (sacubitril/valsartan) for [Patient Name], who has chronic heart failure with reduced ejection fraction (LVEF [X]%) and NYHA Class [X] symptoms. This patient has documented intolerance to [specific ACE inhibitor/ARB] due to [specific adverse effect], making Entresto the appropriate evidence-based therapy per current guidelines."

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Insufficient LVEF documentation" Submit recent echocardiogram Echo report with specific LVEF percentage
"No documented ACE inhibitor trial" Provide medication history Clinic notes showing drug, dose, dates, outcomes
"Step therapy not completed" Document intolerance/contraindication Adverse reaction notes, allergy documentation
"Not prescribed by specialist" Obtain cardiology consultation Specialist evaluation and recommendation
"Quantity exceeds limits" Justify dosing requirements Clinical rationale for specific dosing

For complex denials, Counterforce Health can help analyze your specific situation and draft targeted appeals that address each denial point systematically.

FAQ: Humana Entresto Coverage in Virginia

Q: How long does Humana prior authorization take in Virginia? A: Standard requests: 72 hours. Expedited requests: 24 hours. Submit complete documentation to avoid delays.

Q: What if Entresto is non-formulary on my plan? A: Request a formulary exception with medical necessity documentation. Virginia external review is available if denied.

Q: Can I request an expedited appeal? A: Yes, if your doctor certifies that waiting could seriously jeopardize your health. Virginia allows expedited external review within 72 hours.

Q: Does step therapy apply if I failed ACE inhibitors outside Virginia? A: Yes, document all prior therapy regardless of where it occurred. Include complete medical records.

Q: What's the cost difference between Entresto and alternatives? A: Entresto typically costs several hundred dollars monthly without coverage. Generic ACE inhibitors/ARBs cost $10-50 monthly.

Q: How do I contact Virginia's Bureau of Insurance? A: Call 1-877-310-6560 or visit scc.virginia.gov for external review guidance.

Virginia External Review Process

Virginia provides one of the most patient-friendly external review processes in the country. After completing Humana's internal appeals:

When to Use External Review

  • Internal appeal denied
  • Medical necessity dispute
  • Experimental treatment denial
  • Clinical judgment disagreements

Virginia-Specific Advantages

  • No cost to patients
  • Independent specialist review matching your condition
  • Expedited options for urgent cases
  • Binding decision on insurers
  • Consumer support through Managed Care Ombudsman

Required Forms

Virginia's process has helped many patients access necessary medications when insurers initially denied coverage.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeal processes in Virginia. It is not medical advice. Always consult your healthcare provider for medical decisions and verify current coverage details with Humana. For personalized assistance with appeals and prior authorizations, consider consulting with healthcare advocates or legal professionals specializing in insurance matters.

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