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

Getting Entresto Covered by UnitedHealthcare in North Carolina: Complete Prior Authorization and Appeals Guide

Answer Box: Quick Path to Approval

UnitedHealthcare requires prior authorization for Entresto (sacubitril/valsartan) in North Carolina. To get approved: Your cardiologist must document heart failure with LVEF ≤40%, NYHA Class II-IV symptoms, and prior ACE inhibitor/ARB trial or intolerance. Submit through UnitedHealthcare Provider Portal with recent echocardiogram, clinical notes, and medication history. Standard approval takes 72 hours. If denied, you have 180 days for internal appeals, then 120 days for North Carolina's Smart NC external review process.

Start today: Ask your cardiologist to gather your echo report and document your ACE inhibitor history.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Documentation Needed Source
Prior Authorization Required for all Entresto prescriptions PA form, clinical records UHC Policy
Heart Failure Diagnosis LVEF ≤40% OR HFpEF with structural disease Recent echocardiogram (within 6-12 months) UHC Clinical Criteria
NYHA Class Class II, III, or IV symptoms Clinical notes documenting functional status UHC Policy
Prescriber Cardiologist or consultation required Prescription from qualified specialist UHC Requirements
Prior Therapy ACE inhibitor or ARB trial/intolerance Medication history, documented failure Clinical Guidelines
Safety Check No angioedema history Medical records review FDA Label Requirements

Step-by-Step: Fastest Path to Approval

1. Gather Essential Documentation (Patient + Clinic)

Timeline: 1-2 business days
Who does it: Patient coordinates with clinic staff

  • Recent echocardiogram report (within 6-12 months) showing LVEF measurement
  • Heart failure diagnosis with ICD-10 codes (I50.x series)
  • Complete medication history showing ACE inhibitor or ARB trials
  • Clinical notes documenting NYHA functional class
  • Any prior authorization denial letters (if resubmitting)

2. Complete Prior Authorization Form (Provider)

Timeline: 30 minutes
Who does it: Prescribing cardiologist or clinic staff

Download the current Entresto PA form from UnitedHealthcare's provider portal. Include all clinical justification and supporting documentation.

3. Submit Request (Provider)

Timeline: Same day
Who does it: Provider office

Choose your submission method:

  • Online: UnitedHealthcare Provider Portal (preferred for tracking)
  • Fax: OptumRx at 1-866-434-5523
  • Phone: 1-800-711-4555 for urgent cases

4. Track Status (Provider/Patient)

Timeline: Ongoing monitoring
Who does it: Both parties

Monitor through the OptumRx portal for real-time updates. UnitedHealthcare typically responds within 72 hours for standard requests, 24-48 hours for expedited reviews.

5. Receive Decision

Timeline: 72 hours standard, 24-48 hours expedited
Approval rate: Approximately 91% with complete documentation

When approved, authorizations include:

  • 12-month initial authorization
  • Standard 60-day supply limits
  • Specialty tier placement
  • Required monitoring for kidney function and potassium levels

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Documents Needed
No heart failure diagnosis documented Submit ICD-10 codes and clinical notes Heart failure diagnosis (I50.x), NYHA class documentation
Missing LVEF measurement Provide recent echocardiogram Echo report within 6-12 months showing specific LVEF value
No prior ACE inhibitor trial Document previous therapy attempts Medication history, intolerance documentation, failure notes
Prescriber not qualified Get cardiologist prescription/consultation Cardiologist prescription or consultation letter
Concomitant ACE inhibitor use Confirm medication discontinuation Updated medication list, 36-hour washout documentation
History of angioedema Provide detailed medical history Complete allergy history, specific reaction documentation
From Our Advocates: We've seen cases where patients were initially denied because their primary care doctor prescribed Entresto without cardiology consultation. A simple consultation note from a cardiologist—even if it just confirms the appropriateness of the therapy—often resolves this denial reason quickly. This doesn't mean you need ongoing cardiology care, just documented specialist input.

Appeals Process in North Carolina

If your initial request is denied, North Carolina offers a robust appeals process through multiple levels.

Internal Appeals with UnitedHealthcare

Timeline: 180 days from denial notice
Process: Two-level internal appeal system

  1. First-level appeal: Submit through UnitedHealthcare member portal or by mail
  2. Second-level appeal: Automatic if first level is denied
  3. Peer-to-peer review: Request physician-to-physician discussion

External Review through Smart NC

Timeline: 120 days after final internal denial
Success rate: High overturn rates for well-documented cases

North Carolina's Smart NC program provides free external review through the NC Department of Insurance.

How to request external review:

  1. Download the External Review Request Form
  2. Submit with all denial notices and medical records
  3. Smart NC assigns an Independent Review Organization (IRO)
  4. Decision rendered within 45 days (3 days for expedited cases)

Smart NC Contact: 1-855-408-1212

Note: Smart NC decisions are binding on insurers. If they overturn the denial, UnitedHealthcare must provide coverage within 3 business days.

Medical Necessity Documentation

Clinician Corner: Medical Necessity Letter Checklist

When drafting your medical necessity letter, include these essential elements:

Clinical History:

  • Specific heart failure diagnosis with onset date
  • LVEF measurement with date and method (echo, MRI, nuclear)
  • NYHA functional class with specific symptoms
  • Current medications and dosing

Prior Therapy Documentation:

  • ACE inhibitor or ARB trials with dates, doses, duration
  • Reasons for discontinuation (intolerance, inadequate response, contraindications)
  • Other heart failure medications tried

Treatment Rationale:

Safety Considerations:

  • Confirmation of no angioedema history
  • Plan for ACE inhibitor washout (minimum 36 hours)
  • Contraindications to alternative therapies

Costs and Patient Assistance

Manufacturer Support

Novartis offers the Entresto Savings Card for eligible patients:

  • Commercial insurance patients may pay as little as $10 per month
  • Maximum annual benefit varies by plan
  • Not valid for government insurance (Medicare, Medicaid)

Foundation Programs

Several foundations provide assistance for heart failure medications:

  • Patient Access Network Foundation
  • HealthWell Foundation
  • Good Days (formerly Chronic Disease Fund)

Eligibility varies by income and insurance status. Contact foundations directly for current programs.

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with each payer's specific rules. For cases like Entresto approvals, we pull the right clinical evidence—FDA labeling, peer-reviewed studies, and specialty guidelines—and weave them into appeals with all required documentation.

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take in North Carolina? Standard requests receive decisions within 72 hours of complete submission. Expedited requests for urgent cases are processed within 24-48 hours.

What if Entresto is non-formulary on my plan? Request a formulary exception through the same prior authorization process. Include documentation of why formulary alternatives are inappropriate for your specific case.

Can I request an expedited appeal if I'm hospitalized? Yes. Hospital-based requests and cases where delays could seriously jeopardize health qualify for expedited review through both UnitedHealthcare and North Carolina's Smart NC process.

Does step therapy apply if I failed ACE inhibitors outside North Carolina? Prior therapy trials from any location count toward step therapy requirements. Ensure your new provider has complete medication history documentation.

What happens if my appeal is denied by Smart NC? Smart NC decisions are final for the administrative process. You may have legal options to pursue in court, but this requires consultation with an attorney familiar with insurance law.

How do I know if my UnitedHealthcare plan is regulated by North Carolina? Most individual and small group plans purchased in North Carolina are state-regulated. Large employer self-funded plans may not be subject to North Carolina's external review process. Contact Smart NC at 1-855-408-1212 to verify eligibility.

Can my primary care doctor prescribe Entresto? While any physician can prescribe Entresto, UnitedHealthcare requires either a cardiologist prescription or cardiology consultation for prior authorization approval.

What if I can't afford the copay even with approval? Contact Counterforce Health for assistance identifying additional patient assistance programs and navigating formulary tier appeals to reduce out-of-pocket costs.

Sources & Further Reading

This guide is for informational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms and medical circumstances. For personalized assistance with prior authorization and appeals, consult with your healthcare provider or contact North Carolina's Smart NC program at 1-855-408-1212.

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