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

Getting Entresto (Sacubitril/Valsartan) Covered by UnitedHealthcare in New Jersey: Complete Guide to Prior Authorization and Appeals

Quick Answer: UnitedHealthcare requires prior authorization for Entresto in New Jersey with specific criteria: heart failure diagnosis, LVEF ≤40% or structural heart disease, NYHA Class II-IV, cardiologist prescription, and discontinuation of ACE inhibitors/ARBs. Submit through the UnitedHealthcare provider portal or fax to 1-866-434-5523. If denied, you have 180 days for internal appeals, then can file external review with New Jersey's IHCAP through Maximus Federal Services. Appeals succeed 86% of the time with proper documentation.

Table of Contents

Patient Profile: Who Qualifies for Entresto

Entresto (sacubitril/valsartan) is an ARNI (angiotensin receptor-neprilysin inhibitor) medication prescribed for chronic heart failure to reduce cardiovascular death and hospitalizations. Understanding who qualifies is crucial for a successful prior authorization.

Qualifying Conditions:

  • Chronic heart failure with reduced ejection fraction (HFrEF)
  • Left ventricular ejection fraction (LVEF) ≤40%
  • Heart failure with preserved ejection fraction (HFpEF) with structural heart disease
  • Pediatric symptomatic heart failure ≥1 year with LV systolic dysfunction

Clinical Requirements:

  • NYHA Class II, III, or IV heart failure symptoms
  • No history of angioedema
  • Cardiologist prescription or consultation
  • Discontinuation of ACE inhibitors (36-hour washout required) or ARBs

Meet Sarah, a 68-year-old New Jersey resident with a complex heart failure journey. After her cardiologist documented an LVEF of 35% and NYHA Class III symptoms despite optimal medical therapy with lisinopril and metoprolol, her doctor recommended switching to Entresto. Her case illustrates the typical approval pathway many patients navigate with UnitedHealthcare.

Prior Authorization Preparation

Successful Entresto approval hinges on thorough preparation. Counterforce Health helps patients and clinicians navigate this complex process by turning insurance denials into targeted, evidence-backed appeals through systematic documentation and payer-specific workflows.

Essential Documentation Checklist

Clinical Records Required:

  • Recent echocardiogram showing LVEF ≤40% (within 6-12 months)
  • Heart failure diagnosis with ICD-10 codes (I50.x series)
  • NYHA functional class documentation
  • Complete medication history including ACE inhibitor/ARB trials
  • Documentation of intolerance or inadequate response to previous therapies
  • Absence of contraindications (angioedema history, severe hypotension)

Provider Requirements:

  • Cardiologist prescription or documented consultation
  • Medical necessity letter addressing UnitedHealthcare's specific criteria
  • Treatment goals and expected outcomes
Clinician Corner: Your medical necessity letter should explicitly address each UnitedHealthcare criterion: heart failure diagnosis, LVEF measurement, NYHA class, prior therapy failures, and absence of contraindications. Reference the 2022 AHA/ACC/HFSA Heart Failure Guidelines to support your clinical rationale.

Submission Process and Requirements

UnitedHealthcare processes Entresto prior authorizations through OptumRx with specific submission methods and timelines.

Step-by-Step Submission Process

  1. Gather Documentation (Patient/Clinic)
    • Complete clinical records checklist above
    • Timeline: 1-2 business days
  2. Complete PA Form (Provider)
  3. Submit Request (Provider)
    • Online: UnitedHealthcare Provider Portal
    • Fax: 1-866-434-5523
    • Phone: 1-800-711-4555
    • Timeline: Same day
  4. Track Status (Provider/Patient)
    • Monitor through OptumRx portal
    • Timeline: Real-time updates
  5. Receive Decision (All parties)
    • Standard review: 72 hours with complete documentation
    • Timeline: 1-3 business days

Coverage Requirements Table

Requirement Details Documentation Needed Source
Diagnosis Heart failure (NYHA II-IV) ICD-10 codes, clinical notes UHC PA Form
LVEF ≤40% or structural heart disease Recent echo report UHC PA Form
Prescriber Cardiologist or consultation Provider credentials UHC PA Form
Prior Therapy ACEi/ARB discontinuation Medication history UHC PA Form
Safety No angioedema history Medical records UHC PA Form

Initial Outcome: Approval or Denial

UnitedHealthcare approves approximately 91% of properly documented Entresto requests. When approvals occur, they typically include:

Approval Terms:

  • Initial authorization: 12 months
  • Quantity limits: Standard 60-day supply
  • Tier placement: Specialty tier (typically tier 3-4)
  • Reauthorization required annually

Common Approval Conditions:

  • Regular monitoring of kidney function and potassium levels
  • Dose titration as tolerated
  • Continued cardiologist oversight

Sarah's case proceeded smoothly—her cardiologist submitted complete documentation including her recent echo showing LVEF 35%, documented lisinopril intolerance (persistent cough), and clear NYHA Class III symptoms. UnitedHealthcare approved her request within 48 hours.

Appeals Process in New Jersey

When initial requests are denied, New Jersey offers robust appeal options with high success rates. UnitedHealthcare overturns 86.1% of prior authorization denials upon appeal when proper documentation is provided.

Internal Appeals Process

Level 1 Internal Appeal:

  • Timeline: File within 180 days of denial
  • Decision: 30 days (standard) or 72 hours (expedited)
  • Method: UnitedHealthcare member portal, phone, or mail

Level 2 Internal Appeal:

  • Timeline: File within 60 days of Level 1 denial
  • Decision: 30 days (standard) or 72 hours (expedited)
  • Method: Same as Level 1
Tip: Request a peer-to-peer review during internal appeals. This allows your cardiologist to speak directly with UnitedHealthcare's medical director, often leading to immediate approval.

External Review Through New Jersey IHCAP

New Jersey's Independent Health Care Appeals Program (IHCAP), administered by Maximus Federal Services, provides binding external review.

IHCAP Process:

  • Eligibility: After completing internal appeals
  • Filing deadline: 4 months from final internal denial
  • Standard review: 45 calendar days
  • Expedited review: 48 hours for urgent cases
  • Cost: Free to patients
  • Decision: Binding on UnitedHealthcare

How to File:

Resolution and Key Lessons

Most Entresto appeals succeed when patients and providers understand the process and prepare thoroughly. Counterforce Health's platform streamlines this process by identifying denial reasons and drafting point-by-point rebuttals aligned to payer-specific rules.

What We'd Do Differently

For Providers:

  • Submit complete documentation initially to avoid delays
  • Schedule peer-to-peer reviews proactively
  • Reference specific UnitedHealthcare criteria in medical necessity letters

For Patients:

  • Keep detailed records of all communications
  • Understand your specific UnitedHealthcare plan benefits
  • Don't hesitate to escalate to external review if needed

Key Success Factors:

  • Complete clinical documentation
  • Cardiologist involvement
  • Understanding of UnitedHealthcare's specific criteria
  • Timely appeals when needed

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Missing LVEF documentation Submit recent echocardiogram Echo report with numerical LVEF ≤40%
No cardiologist involvement Obtain cardiology consultation Consultation note or referral
Concurrent ACEi/ARB use Document discontinuation plan Medication reconciliation
Insufficient heart failure documentation Provide comprehensive records ICD-10 codes, symptom documentation, NYHA class
No prior therapy trials Document ACEi/ARB history Medication history with outcomes

Cost-Saving Options

Manufacturer Support:

  • Novartis patient assistance programs
  • Copay cards for eligible patients
  • Income-based discounts

State and Federal Programs:

  • New Jersey pharmaceutical assistance programs
  • Medicare Extra Help for Part D beneficiaries
  • State pharmaceutical assistance to the aged and disabled (PAAD)

Foundation Support:

  • Patient Advocate Foundation
  • HealthWell Foundation
  • Various heart failure-specific foundations

FAQ

How long does UnitedHealthcare prior authorization take in New Jersey? Standard prior authorization decisions are made within 72 hours of receiving complete documentation. Expedited reviews for urgent cases are completed within 24-48 hours.

What if Entresto is non-formulary on my plan? You can request a formulary exception through the same prior authorization process. Provide documentation showing medical necessity and that formulary alternatives are inappropriate.

Can I request an expedited appeal? Yes, if delays would seriously jeopardize your health. Include documentation from your cardiologist explaining why immediate access is medically necessary.

Does step therapy apply if I've tried ACE inhibitors outside New Jersey? Yes, UnitedHealthcare recognizes prior therapy trials regardless of where they occurred. Ensure your medical records document these trials and outcomes.

What happens if my appeal is denied? After exhausting internal appeals, you can file for external review through New Jersey's IHCAP. This independent review is binding and free to patients.

How much does Entresto cost with UnitedHealthcare coverage? Costs vary by plan, but Entresto is typically on specialty tiers with copays ranging from $50-200+ per month. Check your specific plan benefits or contact member services.

Can my family member help with the appeal process? Yes, family members can file appeals on your behalf with written consent. New Jersey's IHCAP specifically allows this.

What if I need Entresto urgently while appeals are pending? Request expedited reviews and ask your cardiologist about temporary supplies or alternative medications while appeals are processed.

This guide provides general information about getting Entresto covered by UnitedHealthcare in New Jersey. It is not medical advice. Always consult your healthcare provider for medical decisions and verify current policy details with your insurer.

For additional support navigating insurance appeals and prior authorizations, Counterforce Health specializes in turning denials into approvals through evidence-based appeals tailored to specific payer requirements.

New Jersey Consumer Assistance:

Sources and Further Reading

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