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

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

Answer Box: Getting Entresto Covered by Aetna CVS Health in Virginia

Entresto requires prior authorization through Aetna CVS Health before coverage. Submit your request via Availity portal or fax to 1-833-280-5224. Include recent echocardiogram showing LVEF ≤40%, documented ACE inhibitor/ARB trial failure, and heart failure diagnosis with NYHA Class II-IV symptoms. Standard decisions take 72 hours; expedited reviews 24 hours. If denied, you have 180 days to appeal internally, then 120 days for Virginia external review via Form 216-A. Start today by gathering your echo results and medication history.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Must get approval before filling Aetna Precert List 2025 Aetna
LVEF ≤40% Recent echo showing reduced ejection fraction Cardiology records CVS Caremark Criteria
ACE/ARB Trial Must try and fail standard therapy first Medical records CVS Caremark
NYHA Class II-IV Documented heart failure symptoms Physician notes CVS Caremark
36-Hour Washout If switching from ACE inhibitor Clinical documentation FDA Label
Appeals Deadline 180 days for internal appeal Member handbook Aetna Policy

Step-by-Step: Fastest Path to Approval

1. Verify Your Coverage (Patient + Clinic)

Call the number on your Aetna insurance card to confirm Entresto requires prior authorization and identify your specific formulary tier. Ask for the current prior authorization criteria document.

2. Gather Required Documentation (Clinic)

Essential documents needed:

  • Recent echocardiogram (within 6 months) showing LVEF ≤40%
  • Heart failure diagnosis with ICD-10 code (typically I50.x)
  • Complete ACE inhibitor or ARB trial history with specific drugs, doses, dates, and outcomes
  • Current NYHA functional class documentation (Class II, III, or IV)
  • Recent lab work (creatinine, potassium levels)

3. Submit Prior Authorization Request (Clinic)

Three submission methods available:

  • Online: Availity portal (fastest processing)
  • Phone: 1-800-279-1878 (24/7 availability)
  • Fax: 1-833-280-5224 for prescription medications
Tip: Electronic submissions through Availity often receive decisions within 6 seconds for automated approvals.

4. Monitor Decision Timeline

  • Standard requests: 72 hours from complete submission
  • Expedited requests: 24 hours if delay would jeopardize health
  • Track status through your provider portal or member services

5. If Approved: Fill and Monitor

Once approved, fill at your preferred pharmacy. CVS Specialty Pharmacy may be required for certain plans - verify with member services.

6. If Denied: Prepare Appeal Documentation

Gather the denial letter, medical records, and any additional supporting evidence for your appeal submission.

7. Submit Appeal Within Deadline

File internal appeal within 180 days of denial notice through member portal or by calling member services.

Prior Authorization Forms and Submission

Required Forms

Aetna CVS Health uses standardized prior authorization request forms available through the Availity portal. Your healthcare provider will complete the electronic form or submit supporting documentation via fax.

Portal Access: Register at Availity.com for fastest processing Integration: Available through CoverMyMeds, Surescripts, and Arrive Health for EHR-integrated submission Response Time: Automated approvals may process in under 6 seconds

Phone and Fax Submission

Phone: 1-800-279-1878 (TTY: 711)

  • Available 24/7
  • Select Prior Authorization option for after-hours voicemail Fax: 1-833-280-5224
  • Include cover sheet with member ID and prescriber information
  • Submit supporting documents with PA request form
Note: Submit precertification requests at least two weeks in advance to allow adequate processing time.

Clinician Corner: Medical Necessity Letter Essentials

When preparing your medical necessity letter for Entresto, include these critical elements:

Clinical Problem Statement:

  • Heart failure diagnosis with specific NYHA functional class
  • Current symptoms and functional limitations
  • Recent LVEF measurement with date of echocardiogram

Prior Treatment History:

  • Specific ACE inhibitor or ARB trials with drug names, doses, and dates
  • Clinical outcomes and reasons for discontinuation
  • Documentation of adverse effects or treatment failures

Clinical Rationale:

  • Reference 2022 AHA/ACC/HFSA Heart Failure Guidelines
  • Explain expected clinical benefits (reduced hospitalizations, improved survival)
  • Address any contraindications to alternative therapies

Monitoring Plan:

  • Laboratory monitoring schedule (creatinine, potassium)
  • Follow-up appointment timeline
  • Safety considerations and washout period if applicable

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
Insufficient LVEF documentation Submit actual echo report with specific percentage Recent echocardiogram showing LVEF ≤40%
No ACE inhibitor/ARB trial Provide detailed medication history Specific drugs, doses, dates, and outcomes
Missing NYHA class Have cardiologist formally document functional class Clinical notes with NYHA Class II-IV
Concomitant ACE inhibitor use Document 36-hour washout period Medical records showing medication timing
Not prescribed by specialist Obtain cardiology consultation Cardiologist recommendation letter
Step therapy not completed Document specific adverse reactions Detailed intolerance/failure documentation

Appeals Playbook for Aetna CVS Health in Virginia

Internal Appeal Process

Timeline: 180 days from denial notice to file appeal Decision Time:

  • Standard appeals: 30 days for pre-service requests
  • Expedited appeals: 72 hours if delay would jeopardize health

Submission Methods:

  • Member portal online
  • Phone: Call number on insurance card
  • Written request to Aetna member services
  • Fax submission with required forms

Peer-to-Peer Review Option

Request a peer-to-peer review where your cardiologist can discuss the case directly with Aetna's medical director. Contact CVS Caremark Prior Authorization Department and specifically request this option on your appeal form.

Contact for Peer-to-Peer:

  • Medicare Part D: 1-855-344-0930
  • Commercial Plans: 1-800-279-1878

Virginia External Review Program

If your internal appeal is unsuccessful, Virginia's external review process provides an independent assessment of your case.

Form 216-A: External Review Request

Filing Deadline: 120 days from final internal denial Required Information:

  • Applicant name and covered person details
  • Insurance company information and claim numbers
  • Employer information
  • Treating healthcare provider details

Submission Address: Virginia Bureau of Insurance P.O. Box 1157 Richmond, VA 23218

Contact Information:

Expedited External Review

For urgent cases, complete Form 216-C (Physician Certification) if your healthcare provider certifies that delay would seriously jeopardize your health.

Decision Timeline:

  • Standard external review: 45 days
  • Expedited review: 72 hours for urgent medical necessity
  • Expedited experimental/investigational: 6 business days
Important: The external review decision is final and binding on both you and the insurance company.

Costs and Financial Assistance

Entresto Co-pay Assistance

Novartis offers a co-pay assistance card for eligible patients. If your mail-order pharmacy cannot process the co-pay offer, submit a rebate form through rebate.patientsavings.com or call 1-888-ENTRESTO (1-888-368-7378).

Additional Support Resources

  • Virginia Poverty Law Center: Health assistance program for Medicaid and ACA marketplace issues
  • Patient Advocate Foundation: Financial assistance for specialty medications
  • Manufacturer Patient Support: Contact Novartis directly for additional programs

When to Contact Virginia Regulators

Virginia Bureau of Insurance Consumer Services

Contact the Bureau if you experience:

  • Unreasonable delays in prior authorization decisions
  • Repeated denials without adequate medical review
  • Procedural violations in the appeals process

Contact Information:

Virginia Managed Care Ombudsman

The Office of the Managed Care Ombudsman assists with HMO and managed care plan issues and can sometimes informally resolve coverage disputes.

From Our Advocates: We've seen cases where patients succeeded in getting Entresto covered after initial denials by working closely with their cardiologist to document specific ACE inhibitor intolerance (such as persistent cough or hyperkalemia) rather than simply stating "patient couldn't tolerate." The key was providing exact dates, doses, and clinical notes showing the adverse effects. This detailed documentation approach significantly improved approval rates in our experience.

Frequently Asked Questions

Q: How long does Aetna CVS Health prior authorization take in Virginia? A: Standard requests receive decisions within 72 hours. Expedited reviews are completed within 24 hours if delay would jeopardize your health.

Q: What if Entresto is non-formulary on my plan? A: You can request a formulary exception by providing medical necessity documentation showing why Entresto is required despite not being on your plan's preferred drug list.

Q: Can I request an expedited appeal in Virginia? A: Yes, expedited appeals are available within 72 hours if your healthcare provider certifies that waiting could seriously jeopardize your health.

Q: Does step therapy apply if I failed ACE inhibitors outside Virginia? A: Yes, step therapy requirements apply regardless of where previous treatment occurred. Provide complete medical records from your prior ACE inhibitor or ARB trials.

Q: What happens if I'm taking an ACE inhibitor when starting Entresto? A: You must complete a 36-hour washout period from ACE inhibitors before starting Entresto due to angioedema risk. This must be documented in your medical records.

Q: Can my primary care doctor prescribe Entresto? A: While primary care doctors can prescribe Entresto, some insurance plans require cardiology consultation or specialist recommendation for approval.

Q: What if my appeal is denied by Aetna? A: You can file for external review with Virginia's Bureau of Insurance using Form 216-A within 120 days of the final internal denial.

Q: Are there alternatives if Entresto isn't covered? A: Alternative heart failure medications include ACE inhibitors, ARBs, SGLT2 inhibitors, and beta-blockers, though your cardiologist will determine the most appropriate option for your specific condition.

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals for prescription medications like Entresto. Our platform analyzes denial letters and plan policies to identify the specific denial basis, then drafts point-by-point rebuttals aligned with your insurer's own rules, incorporating the right clinical evidence and procedural requirements to maximize approval chances.

For patients and clinicians navigating complex prior authorization requirements, having the right documentation and appeal strategy can make the difference between coverage approval and ongoing denials. Counterforce Health helps streamline this process by providing the clinical and procedural expertise needed to successfully appeal coverage decisions.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on your specific insurance plan and medical circumstances. Always consult with your healthcare provider and insurance company for personalized guidance. For assistance with appeals or coverage issues in Virginia, contact the Bureau of Insurance Consumer Services at 1-877-310-6560.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.