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

How to Get Entresto (Sacubitril/Valsartan) Covered by Aetna CVS Health in Texas: Complete Appeals Guide with Forms and Timelines

Quick Answer: Getting Entresto Covered by Aetna CVS Health in Texas

Aetna CVS Health requires prior authorization for Entresto (sacubitril/valsartan), with decisions made within 72 hours for non-urgent requests. If denied, you have 180 days to file an internal appeal through your member portal or by calling the number on your insurance card. Texas law provides additional protection through Independent Review Organization (IRO) external appeals if internal appeals fail. The fastest path: gather your heart failure diagnosis documentation, prior ACE inhibitor/ARB trial records, and current LVEF results before your doctor submits the PA request.

Table of Contents

  1. Understanding Your Aetna CVS Health Coverage
  2. Prior Authorization Requirements
  3. Reading Your Denial Letter
  4. First-Level Internal Appeal
  5. Medical Necessity Letter Template
  6. Peer-to-Peer Review Process
  7. Texas External Review (IRO) Process
  8. Common Denial Reasons and Solutions
  9. Cost Assistance Options
  10. When to Escalate
  11. Frequently Asked Questions

Understanding Your Aetna CVS Health Coverage

Entresto is subject to Aetna's prior authorization requirements and formulary placement varies by plan type. Most Aetna plans managed through CVS Caremark require approval before dispensing, with coverage determination decisions made within 72 hours for standard requests and 24 hours for expedited reviews.

During your first 90 days of membership, Aetna may provide temporary coverage while you pursue a formal formulary exception request, even if Entresto isn't initially on your plan's formulary.

Tip: Log into your Aetna member portal or call the number on your insurance card to check Entresto's specific tier placement and any quantity limits for your plan before starting the PA process.

Prior Authorization Requirements

Essential Documentation Checklist

Before your doctor submits the prior authorization request, gather:

  • Heart failure diagnosis with ICD-10 code (typically I50.x)
  • Recent echocardiogram showing LVEF ≤40% (within past 6 months)
  • Prior medication history documenting ACE inhibitor or ARB trial
  • Current symptoms and NYHA functional class
  • Prescriber credentials (cardiologist or consultation with cardiology)

Coverage Criteria

Aetna typically requires patients to meet these criteria:

  • Age 18 years or older
  • Chronic heart failure with NYHA Class II-IV symptoms
  • LVEF ≤40% documented by recent imaging
  • Trial and documented failure/intolerance of at least one ACE inhibitor or ARB
  • No history of angioedema
  • 36-hour washout period from prior ACE inhibitor

Reading Your Denial Letter

When Aetna denies your Entresto request, the denial letter will specify the reason. Common codes include:

Denial Reason What It Means How to Address
Lack of medical necessity Insufficient clinical documentation Submit comprehensive medical necessity letter
Step therapy not met Must try preferred alternatives first Document ACE inhibitor/ARB failure or intolerance
Non-formulary Drug not on preferred list Request formulary exception with clinical justification
Quantity limits exceeded Prescribed amount exceeds plan limits Provide dosing rationale and clinical need

The denial letter will also include important deadlines—typically 180 days to file an internal appeal.

First-Level Internal Appeal

How to File

Submit your appeal through one of these methods:

  • Online: Aetna member portal (fastest option)
  • Phone: Number on your insurance card
  • Mail: Address provided in denial letter
  • Fax: Provider appeals can be submitted to 1-800-408-2386

Required Documentation

Include these items with your appeal:

  1. Completed appeal form (if required by your plan)
  2. Medical necessity letter from prescribing physician
  3. Clinical notes supporting diagnosis and treatment history
  4. Recent echocardiogram results showing LVEF
  5. Prior medication trial documentation
  6. Current heart failure guidelines supporting Entresto use

Timeline Expectations

  • Standard appeals: 30 days for pre-service requests
  • Expedited appeals: 72 hours (available if delay would jeopardize health)
  • Post-service appeals: 60 days for services already received

Medical Necessity Letter Template

Your doctor's medical necessity letter should include these key sections:

Patient Information Section

  • Name, date of birth, member ID
  • Heart failure diagnosis with ICD-10 code
  • Date of initial diagnosis and duration of care

Clinical History Section

[Patient Name] is a [age]-year-old patient with chronic heart failure 
diagnosed on [date]. Current NYHA functional class is [II/III/IV] 
with symptoms including [specific symptoms]. Recent echocardiogram 
dated [date] shows LVEF of [%].

Prior Therapy Documentation

Critical requirement: Document specific ACE inhibitor or ARB trials:

Patient previously trialed [medication name] [dose] daily for [duration] 
from [start date] to [end date]. Therapy was discontinued due to 
[specific reason: dry cough/hyperkalemia/hypotension/angioedema].

Clinical Justification

Reference current heart failure guidelines and FDA labeling that support Entresto use in patients with reduced ejection fraction heart failure.

Peer-to-Peer Review Process

If your initial appeal is denied, request a peer-to-peer review where your cardiologist can discuss the case directly with Aetna's medical director.

How to Request

Contact CVS Caremark Prior Authorization Department and specifically request a peer-to-peer review. Include this request on your appeal submission form.

Preparation Checklist for Your Doctor

  • Patient's complete heart failure history
  • Specific reasons ACE inhibitors/ARBs failed or are contraindicated
  • Current functional status and quality of life impact
  • Evidence from heart failure guidelines supporting Entresto use
  • Any unique clinical circumstances

Counterforce Health helps physicians prepare for these conversations by identifying payer-specific criteria and drafting evidence-based talking points that align with Aetna's coverage policies.

Texas External Review (IRO) Process

If Aetna denies your internal appeal, Texas law provides an additional layer of protection through Independent Review Organization (IRO) external review.

Eligibility Requirements

  • Must have completed Aetna's internal appeal process
  • Denial must be based on medical necessity, appropriateness, or experimental/investigational determination
  • Must file within 45 calendar days of final internal denial

How to Request IRO Review

  1. Complete Form LHL009 (available at tdi.texas.gov or call 866-554-4926)
  2. Submit to Aetna within 45 days of final denial
  3. Aetna forwards to TDI within one working day
  4. TDI assigns certified IRO and notifies all parties

IRO Timeline

  • Life-threatening conditions: 8 days
  • Preauthorization reviews: 20 days
  • Retrospective reviews: 30 days (fee may apply)

The IRO decision is binding—if they overturn Aetna's denial, the insurer must cover Entresto.

Common Denial Reasons and Solutions

Denial Reason Solution Strategy
"No documentation of heart failure" Submit recent echo, BNP/NT-proBNP levels, clinical notes
"Concomitant ACE inhibitor use" Confirm 36-hour washout documented in medical records
"No prior ACE inhibitor trial" Provide detailed medication history with specific drugs, doses, dates
"Not prescribed by cardiologist" Include cardiology consultation notes or referral
"Experimental/investigational" Cite FDA approval and current heart failure guidelines

Cost Assistance Options

While pursuing coverage, consider these financial support options:

Manufacturer Support

  • Entresto Copay Card: May reduce out-of-pocket costs for eligible commercially insured patients
  • Novartis Patient Assistance Program: Income-based assistance for uninsured/underinsured patients

State and Federal Programs

  • Texas Medicaid: Covers Entresto with prior authorization for eligible recipients
  • Medicare Part D: Coverage varies by plan; Low Income Subsidy available for qualifying beneficiaries

When to Escalate

If all appeals fail, you have additional options in Texas:

Texas Department of Insurance

  • Consumer Helpline: 1-800-252-3439
  • File Complaint: Available online at tdi.texas.gov
  • IRO Information Line: 1-866-554-4926

Office of Public Insurance Counsel (OPIC)

  • Helpline: 1-877-611-6742
  • Provides guidance on appealing denied claims and understanding your rights

Disability Rights Texas

Offers assistance with insurance appeals, particularly for complex cases involving specialty medications.

From our advocates: We've seen cases where patients succeeded on external review after providing more detailed documentation of functional limitations and quality of life impacts that weren't included in the initial appeal. The key is showing how heart failure symptoms specifically interfere with daily activities and why Entresto is medically necessary despite available alternatives.

Frequently Asked Questions

How long does Aetna CVS Health prior authorization take for Entresto in Texas? Standard decisions are made within 72 hours; expedited reviews within 24 hours if delay would jeopardize health.

What if Entresto is non-formulary on my Aetna plan? Request a formulary exception with clinical justification. Aetna will cover at a predetermined cost-sharing level if approved.

Can I request an expedited appeal if my condition is urgent? Yes, expedited appeals are available within 72 hours if standard timing would jeopardize your health.

Does step therapy apply if I've tried ACE inhibitors outside Texas? Yes, prior therapy trials from any location count toward meeting step therapy requirements.

What happens if my doctor isn't a cardiologist? Include documentation of cardiology consultation or referral, or have your primary care physician coordinate with a cardiologist for the PA request.

How much does the Texas IRO process cost? There's no cost for patients except potentially for retrospective reviews, and injured employees cannot be charged IRO fees.

What if I'm on a self-funded employer plan? Self-funded ERISA plans follow federal appeals processes rather than Texas state IRO procedures, but you still have appeal rights.

Can I continue current therapy while appealing? If you're already on Entresto and coverage is being discontinued, request continuation of benefits during the appeal process.

When navigating complex prior authorization and appeals processes, platforms like Counterforce Health can help by identifying specific denial reasons and drafting evidence-backed responses that align with Aetna's coverage criteria, potentially improving your chances of approval.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance company for specific guidance regarding your situation. For official Texas insurance regulations and appeal procedures, visit the Texas Department of Insurance website.

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