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

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

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

Aetna (CVS Health) requires prior authorization for Entresto (sacubitril/valsartan) in heart failure with reduced ejection fraction (LVEF ≤40%). Submit complete documentation through the Aetna provider portal or fax 1-859-425-3379 within 14 days for approval. If denied, appeal within 180 days internally, then request external review through North Carolina's Smart NC program (1-855-408-1212) for binding decisions within 45 days.

Next steps: Verify active Aetna coverage, gather echocardiogram showing LVEF ≤40%, document prior ACE inhibitor/ARB failures, and submit PA form with medical necessity letter.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria for Approval
  4. Documentation Requirements
  5. Submission Process
  6. CVS Specialty Pharmacy Enrollment
  7. Appeals Process in North Carolina
  8. Common Denial Reasons & Solutions
  9. Costs & Patient Assistance
  10. Frequently Asked Questions

Who Should Use This Guide

This guide helps North Carolina patients and their healthcare providers navigate Aetna (CVS Health) coverage for Entresto (sacubitril/valsartan), a heart failure medication that reduces cardiovascular death and hospitalizations in patients with reduced ejection fraction.

You'll benefit from this guide if you:

  • Have chronic heart failure with LVEF ≤40%
  • Need to switch from ACE inhibitors or ARBs due to side effects or lack of effectiveness
  • Received an Aetna prior authorization denial for Entresto
  • Want to understand North Carolina's external review rights

Expected outcome: With complete documentation, Aetna approves ~93% of properly submitted Entresto requests. Appeals succeed in 82% of cases with adequate evidence.

Member & Plan Basics

Verify Your Coverage

Before starting, confirm your Aetna (CVS Health) plan details:

  • Active coverage: Call member services at the number on your insurance card
  • Plan type: Commercial, Medicare Advantage, or Medicaid managed care
  • Pharmacy benefits: Managed by CVS Caremark
  • Specialty pharmacy requirement: Entresto must be dispensed through CVS Specialty Pharmacy
Tip: Download the Aetna mobile app or log into your member portal to check formulary status and prior authorization requirements for your specific plan.

Clinical Criteria for Approval

Aetna (CVS Health) approves Entresto for patients meeting these FDA-approved indications:

Coverage Requirements Table

Requirement Details Documentation Needed
Diagnosis Chronic systolic heart failure ICD-10: I50.22, provider notes
Ejection Fraction LVEF ≤40% (within 6-12 months) Echocardiogram report
Symptoms NYHA Class II-IV Cardiology notes/consultation
Step Therapy Prior ACE inhibitor or ARB trial Medication history with doses, duration, failure reason
Prescriber Cardiologist or cardiology consultation Provider NPI and specialty verification
Safety Labs Normal potassium, adequate kidney function Recent creatinine, potassium levels

Key Clinical Points

Contraindications that prevent approval:

  • History of angioedema with ACE inhibitors or ARBs
  • Concurrent use with ACE inhibitors (36-hour washout required)
  • Concurrent use with aliskiren in patients with diabetes

Pediatric indication: Also approved for children ≥1 year with symptomatic heart failure and left ventricular systolic dysfunction.

Documentation Requirements

Essential Documents Checklist

Patient Information:

  • Full name, date of birth, Aetna member ID
  • Current medications and allergies
  • Complete medical history

Clinical Evidence:

  • Echocardiogram report with LVEF measurement and date
  • Cardiology consultation notes
  • NYHA functional class documentation
  • Recent labs (BNP/NT-proBNP, creatinine, potassium)

Step Therapy Documentation:

  • Previous ACE inhibitor or ARB trials with specific medications, doses, duration
  • Reason for discontinuation (side effects, lack of efficacy, contraindications)
  • Documentation of 36-hour washout from ACE inhibitors if applicable

Clinician Corner: Medical Necessity Letter

Your medical necessity letter should include:

  1. Patient background: Age, heart failure history, current symptoms
  2. Objective findings: LVEF value, NYHA class, relevant lab values
  3. Prior therapy failures: Specific ACE inhibitor/ARB trials and outcomes
  4. Clinical rationale: Why Entresto is superior to alternatives
  5. Evidence base: Reference to PARADIGM-HF trial showing 20% reduction in cardiovascular death
  6. Monitoring plan: Follow-up schedule for safety and efficacy
Note: Include specific guideline references such as the 2022 AHA/ACC/HFSA Heart Failure Guidelines that recommend ARNIs like Entresto as first-line therapy for HFrEF.

Submission Process

Step-by-Step: Fastest Path to Approval

1. Gather Documentation (1-2 days)

  • Collect echocardiogram, medication history, lab results
  • Ensure all documents are recent (within 6-12 months for echo)

2. Complete Prior Authorization Form (30 minutes)

  • Access through Aetna provider portal or request by calling 1-800-872-3862
  • Include patient demographics, ICD-10 code I50.22, LVEF value, prescriber NPI

3. Submit Medical Necessity Letter (15-30 minutes)

  • Address heart failure history, LVEF documentation, prior therapy failures
  • Reference clinical guidelines and monitoring plan

4. Submit Complete Package

  • Online: Aetna provider portal (fastest processing)
  • Fax: 1-859-425-3379
  • Phone: 1-877-433-7643 for urgent cases

5. Track Your Request

  • Record confirmation number
  • Check status at 7 days
  • Standard decisions within 14 days; expedited within 72 hours

CVS Specialty Pharmacy Enrollment

Once Aetna approves your prior authorization, Entresto must be dispensed through CVS Specialty Pharmacy.

Enrollment Process

  1. Prescription Transfer: Your prescriber sends the prescription to CVS Specialty
  2. Patient Contact: CVS CareTeam calls within 48 hours to verify information
  3. Clinical Screening: Pharmacists review drug interactions and contraindications
  4. Delivery Setup: Choose home delivery, doctor's office, or CVS Pharmacy pickup (where legally permitted)

Contact CVS Specialty: 1-800-237-2767

Important: Oklahoma residents cannot pick up specialty medications at retail CVS locations due to state regulations.

Appeals Process in North Carolina

If Aetna denies your prior authorization, North Carolina offers robust appeal rights through multiple levels.

Internal Appeals (Aetna)

Timeline: 180 days to file; 30-45 day response (72 hours for expedited)

How to submit:

  • Online through Aetna member portal
  • Mail to address provided in denial letter
  • Fax with tracking confirmation

Required documents:

  • Original denial letter
  • Additional medical evidence
  • Updated provider letter addressing denial reasons

External Review (Smart NC)

If internal appeals fail, North Carolina's Smart NC program provides independent review.

Key Benefits:

  • Free service with binding decisions
  • 45-day timeline for standard reviews (72 hours expedited)
  • Expert review by independent medical professionals
  • High success rate for properly documented cases

How to Request External Review:

  1. Call Smart NC at 1-855-408-1212
  2. Complete external review request form
  3. Submit within 120 days of final internal denial
  4. Include all relevant medical records

Eligibility: Must have state-regulated insurance plan (not self-funded employer plans unless they opted into NC's system)

Tip: Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters and crafting point-by-point rebuttals aligned to each plan's specific policies.

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
No LVEF documentation Submit recent echocardiogram Echo report with LVEF ≤40%
Step therapy not met Document ACE inhibitor/ARB failures Medication history with specific trials
Non-formulary status Request formulary exception Medical necessity letter with alternatives comparison
Quantity limits exceeded Justify dosing requirements Clinical notes supporting prescribed dose
Missing cardiology consultation Obtain specialist evaluation Cardiology consultation note

Sample Appeal Script for Patients

"I'm calling to appeal the denial of my Entresto prescription. My member ID is [number]. I have heart failure with an ejection fraction of [X]%, and I've tried [specific ACE inhibitor/ARB] but had [specific side effect/lack of response]. My cardiologist believes Entresto is medically necessary based on clinical guidelines. I have additional documentation to submit."

Costs & Patient Assistance

Potential Costs

  • Brand pricing: Typically several hundred dollars per month
  • Copay/coinsurance: Varies by Aetna plan tier
  • Specialty pharmacy fees: May apply for delivery/clinical services

Savings Options

Novartis Patient Assistance:

  • Copay savings program for eligible commercial insurance patients
  • Patient assistance program for uninsured/underinsured
  • Contact: 1-844-4-ENTRESTO

Foundation Grants:

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

North Carolina Resources:

  • 211 North Carolina for local assistance programs
  • North Carolina Department of Health and Human Services medication assistance

Frequently Asked Questions

Q: How long does Aetna prior authorization take for Entresto? A: Standard requests typically receive decisions within 14 days. Expedited requests (when health is at immediate risk) are processed within 72 hours.

Q: What if Entresto is not on my Aetna formulary? A: You can request a formulary exception by demonstrating medical necessity and that preferred alternatives are inappropriate or ineffective.

Q: Can I get an expedited appeal in North Carolina? A: Yes, both Aetna internal appeals and Smart NC external reviews offer expedited processing (72 hours) when delays could seriously jeopardize your health.

Q: Does step therapy apply if I tried ACE inhibitors outside North Carolina? A: Yes, documented trials from any state count toward step therapy requirements. Ensure you have complete records from previous providers.

Q: What happens if Smart NC overturns Aetna's denial? A: The decision is binding. Aetna must provide coverage within 3 business days of the external review decision.

Q: Can I use retail pharmacies for Entresto with Aetna coverage? A: No, Aetna requires specialty medications like Entresto to be dispensed through CVS Specialty Pharmacy for covered members.

When to Escalate

Contact North Carolina regulators if you experience:

  • Delays beyond published timeframes
  • Improper denial of expedited requests
  • Failure to honor external review decisions

North Carolina Department of Insurance

  • Phone: 1-855-408-1212 (Smart NC)
  • Online: ncdoi.gov
  • Consumer Services Division for formal complaints

Healthcare coverage can be complex, but Counterforce Health helps patients and providers navigate these challenges by creating targeted appeals that address specific denial reasons with evidence-backed responses.

Printable Checklist: Before You Start

Patient Preparation:

  • Insurance card with member ID
  • List of current medications
  • Heart failure diagnosis documentation
  • Recent echocardiogram results

Provider Requirements:

  • Cardiology consultation or notes
  • Documentation of prior ACE inhibitor/ARB trials
  • Recent lab results (creatinine, potassium, BNP)
  • Medical necessity letter

Submission:

  • Complete PA form
  • Submit via provider portal or fax
  • Record confirmation number
  • Set calendar reminder for follow-up

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult your healthcare provider for medical decisions and verify current insurance policies with your plan. Coverage policies and requirements may change. For personalized assistance with insurance appeals, consider consulting with healthcare advocates or legal professionals specializing in insurance matters.

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