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

How to Get Entresto (sacubitril/valsartan) Covered by Aetna (CVS Health) in California: Complete Prior Authorization Guide

Answer Box: Getting Entresto Covered by Aetna (CVS Health) in California

Entresto (sacubitril/valsartan) requires prior authorization from Aetna (CVS Health) on most 2024-2025 California plans. Fastest path: Submit the California-specific PA form with complete heart failure documentation (LVEF ≤40%, NYHA class, prior ACE/ARB history) via Aetna's provider portal. Standard decisions take 72 hours; expedited reviews for urgent heart failure cases take 24 hours. If denied, California residents can request an Independent Medical Review (IMR) with ~60% overturn rates for medical necessity denials.

Table of Contents

What This Guide Covers

This guide helps patients with heart failure and their clinicians navigate Aetna (CVS Health) prior authorization for Entresto (sacubitril/valsartan) in California. We'll cover the fastest approval pathways, required documentation, appeal strategies, and California-specific patient rights.

Who this helps: Patients with chronic heart failure with reduced ejection fraction (HFrEF), their caregivers, and healthcare providers working with Aetna commercial, Medicare, or Medicaid plans in California.

Expected outcome: With complete documentation, most medically appropriate Entresto requests are approved within 3-5 business days. If denied initially, California's robust appeal system offers strong patient protections.

Before You Start: Verify Your Coverage

Step 1: Confirm Your Plan Type

Check your Aetna member ID card to identify your specific plan:

  • Commercial/Employer plans: Advanced Control, Basic Control, Standard Plan
  • California Exchange: Aetna Health Exchange Plan
  • Medicare: Aetna Medicare Advantage or Part D
  • Medicaid: Aetna Better Health (California)

Step 2: Verify Entresto's Formulary Status

Entresto appears on Aetna's 2025 formularies as a preferred brand (Tier 2) drug with prior authorization (PA), step therapy (ST), and quantity limit (QL) requirements.

Plan Type Formulary Tier Requirements
Commercial/Exchange Tier 2 (Preferred Brand) PA + ST + QL
Medicare Varies by plan PA required
Medicaid Covered with restrictions PA + clinical criteria

Step 3: Understand Coverage Criteria

Aetna's Entresto policy requires:

  • Chronic heart failure with reduced ejection fraction (LVEF ≤40%)
  • NYHA Class II-IV symptoms
  • Prior ACE inhibitor or ARB trial (with 36-hour washout documented)
  • No history of angioedema
  • Prescriber specialty (cardiology preferred)

Gather Required Documentation

Clinical Documentation Checklist

Essential items for approval:

  • Recent echocardiogram showing LVEF ≤40% (within 6-12 months)
  • ICD-10 diagnosis codes (I50.x for heart failure)
  • NYHA functional class documentation
  • Complete medication history with ACE/ARB trials, doses, and outcomes
  • Current vital signs and laboratory values (potassium, creatinine)
  • Cardiology consultation notes (if available)

Safety documentation:

  • No history of angioedema with ACE inhibitors or ARBs
  • Blood pressure stability on current regimen
  • Kidney function assessment (eGFR)
Tip: Counterforce Health helps clinicians compile this evidence into targeted, payer-specific appeals that address each denial criterion systematically. The platform pulls relevant FDA labeling, clinical guidelines, and formulary policies to strengthen medical necessity arguments.

Forms and Submission Methods

Primary submission options:

  1. Electronic (fastest): Aetna provider portal or Availity
  2. Fax: 1-888-836-0730 (non-specialty) or 1-866-249-6155 (specialty drugs)
  3. Mail: Aetna Medical Exception Unit (address in current drug guide)

Download the California-specific Entresto PA form for accurate submission.

Submit Your Prior Authorization Request

Step-by-Step Submission Process

1. Complete the PA form thoroughly

  • Patient demographics and Aetna member ID
  • Prescriber information including NPI and specialty
  • Entresto dosing: strength, frequency, quantity, duration
  • Primary diagnosis with ICD-10 codes
  • Clinical justification addressing all Aetna criteria

2. Attach supporting documentation

  • Medical necessity letter from prescriber
  • Recent echocardiogram report
  • Medication trial history
  • Relevant clinic notes

3. Submit via preferred method

  • Electronic submission processes fastest (24-72 hours)
  • Mark as "urgent" only if patient has immediate clinical risk
  • Keep confirmation numbers for tracking

4. Notify the patient

  • Explain the review timeline
  • Provide reference number for follow-up
  • Set expectations for potential follow-up requests

Timeline Expectations

Request Type Decision Timeline
Standard (non-urgent) 72 hours
Urgent/expedited 24 hours
Incomplete submissions Additional 2-3 business days
Note: Under California law, if Aetna doesn't decide within the mandated timeframe, the request is deemed approved and cannot be later denied.

Follow-Up Timeline and Process

When to Follow Up

  • Day 2: Check submission status via provider portal
  • Day 4: Call if no decision on standard request (1-800 number on member card)
  • Day 1: Call immediately if urgent request has no response

Sample Follow-Up Script

"Hi, I'm calling to check the status of a prior authorization for Entresto for [patient name], member ID [number]. The request was submitted [date] with reference number [if available]. Can you confirm receipt and provide an estimated decision date?"

Document everything: Date, time, representative name, reference numbers, and next steps.

Common Denial Reasons & How to Fix Them

Denial Reason Fix Strategy Required Documentation
"Missing LVEF documentation" Submit recent echo report Echocardiogram with numerical LVEF ≤40%
"Step therapy not met" Document ACE/ARB trial or contraindication Medication history with doses, duration, outcomes
"Not medically necessary" Provide clinical justification Medical necessity letter citing guidelines
"Concomitant ACE inhibitor" Show medication reconciliation Current med list with 36-hour washout plan
"Missing specialty consultation" Include cardiology notes Cardiology evaluation or co-management plan

Medical Necessity Letter Template

Your prescriber should address:

  1. Patient's condition: HFrEF with LVEF, NYHA class, symptoms
  2. Prior treatments: ACE/ARB trials with specific drugs, doses, duration, and reasons for discontinuation
  3. Clinical rationale: Why Entresto is necessary based on 2022 AHA/ACC/HFSA Heart Failure Guidelines
  4. Safety considerations: Monitoring plan, contraindication screening
  5. Treatment goals: Symptom improvement, hospitalization reduction, mortality benefit

California Appeals Process

Internal Appeal (First Level)

Timeline: Must file within 180 days of denial Process: Submit via Aetna member portal or mail with:

  • Original denial letter
  • Additional clinical evidence
  • Updated medical necessity letter
  • Any new test results or specialist consultations

Decision timeline: 30 days for standard appeals, 72 hours for urgent

Independent Medical Review (IMR)

If Aetna upholds the denial, California residents can request an Independent Medical Review through DMHC.

Success rates: Approximately 60% of medical necessity denials are overturned in the patient's favor Timeline: 30 days for standard IMR, 3-7 days for urgent cases Cost: Free to patients

To request IMR:

  1. Complete internal appeal first (unless urgent)
  2. File IMR application within required timeframe
  3. Submit all medical records and supporting evidence
  4. DMHC assigns independent physician reviewer
From our advocates: We've seen cases where patients initially denied for "experimental" designation successfully appealed by emphasizing Entresto's FDA approval for their specific heart failure type and providing current guideline recommendations. The key was having the cardiologist write a detailed letter explaining why this wasn't experimental but rather standard-of-care therapy that other treatments had failed to provide.

External Resources

DMHC Help Center: 1-888-466-2219

  • File complaints about delayed decisions
  • Get assistance with IMR applications
  • Report plan compliance issues

Health Consumer Alliance: Nonprofit providing free appeal assistance for complex cases

Renewal and Re-Authorization

Planning for Renewal

Most Entresto approvals are granted for 6-12 months. Set calendar reminders 30 days before expiration to:

Gather updated documentation:

  • Recent echocardiogram showing continued need
  • Clinic notes documenting treatment response
  • Any hospitalizations or emergency visits
  • Current medication list and adherence

Demonstrate medical necessity:

  • Symptom improvement or stabilization
  • Functional status changes
  • Hospitalization reduction
  • Quality of life improvements

Renewal Submission

Use the same process as initial authorization but emphasize:

  • Positive treatment response
  • Continued medical necessity
  • Lack of alternative treatments
  • Safety and tolerability

Patient Support and Cost Savings

Manufacturer Support

Entresto Savings Program: Eligible commercially insured patients may pay as little as $10 for a 90-day supply. Check Entresto.com financial support for current eligibility.

Additional Resources

  • Novartis Patient Assistance Program: For uninsured or underinsured patients
  • California Prescription Drug Discount Program: State-sponsored savings
  • GoodRx: Compare pharmacy prices and access coupons

The team at Counterforce Health specializes in turning insurance denials into successful appeals by identifying specific denial reasons and crafting evidence-backed responses that align with each payer's criteria.

FAQ

How long does Aetna prior authorization take in California? Standard requests: 72 hours. Urgent requests: 24 hours. If Aetna exceeds these timeframes, the request is automatically approved.

What if Entresto is not on my formulary? Request a formulary exception with medical necessity documentation. Your prescriber can submit this with the initial PA request.

Can I request an expedited appeal? Yes, if delay poses serious health risks. Document immediate clinical need (e.g., recent hospitalization, worsening symptoms).

Does step therapy apply if I tried ACE inhibitors outside California? Yes, medication trials from any state count. Provide complete documentation of prior treatments.

What happens if my appeal is denied? You can request Independent Medical Review (IMR) through California DMHC, which has favorable overturn rates for appropriate cases.

How much does Entresto cost without insurance? Brand pricing varies but typically ranges from $400-600 per month. Generic versions are becoming available.

Can I use CVS Specialty Pharmacy? Yes, Aetna often routes specialty medications through CVS Specialty. They'll coordinate with your prescriber after PA approval.

What if I can't afford the copay? Check manufacturer copay programs, patient assistance programs, and California state pharmaceutical assistance options.

Printable Checklist

Before You Start

  • Verify Aetna plan type and formulary status
  • Confirm in-network prescriber
  • Check current medication list for conflicts

Required Documentation

  • Recent echocardiogram (LVEF ≤40%)
  • Heart failure diagnosis with ICD-10 codes
  • NYHA class documentation
  • ACE inhibitor/ARB trial history
  • Current vital signs and labs
  • Medical necessity letter

Submission

  • Complete California-specific PA form
  • Submit via Aetna provider portal (preferred)
  • Keep confirmation number
  • Mark urgent only if clinically appropriate

Follow-Up

  • Check status after 2 business days
  • Call if no decision by day 4 (standard) or day 1 (urgent)
  • Document all communications

If Denied

  • Review denial reason carefully
  • Gather additional evidence
  • File internal appeal within 180 days
  • Consider IMR if internal appeal fails

Disclaimer: This guide provides educational information about insurance processes and is not medical advice. Always consult your healthcare provider about treatment decisions. For assistance with insurance appeals or coverage questions, contact your plan directly or seek help from qualified patient advocates.

Sources & Further Reading

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