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

How to Get Entresto (sacubitril/valsartan) Covered by Blue Cross Blue Shield in Florida: Complete Forms, Appeals & Contact Guide

Answer Box: Getting Entresto Covered by Florida Blue Cross Blue Shield

Entresto (sacubitril/valsartan) requires prior authorization from Florida Blue Cross Blue Shield in 2024. Your doctor must submit a PA request form showing you meet clinical criteria—typically heart failure with reduced ejection fraction and documented failure/intolerance to ACE inhibitors or ARBs (step therapy). The fastest path: have your physician call 1-877-719-2583 or contact Prime Therapeutics at (800) 424-4947 to initiate the request. Submit all required documentation including diagnosis, prior medication trials, and clinical justification. If denied, you have 180 days to file an internal appeal, followed by external review through Florida's Department of Financial Services if needed.

Table of Contents

  1. Verify Your Plan & Find the Right Forms
  2. Prior Authorization Forms & Requirements
  3. Submission Portals & Electronic Access
  4. Fax Numbers & Mailing Addresses
  5. Specialty Pharmacy Setup
  6. Support Phone Lines & Contact Information
  7. Florida Appeals & External Review Process
  8. When to Update Your Resources

Coverage at a Glance: Entresto with Florida Blue

Requirement What It Means Where to Find It Source
Prior Authorization Required before coverage Florida Blue member portal or call 1-877-719-2583 Florida Blue PA Info
Formulary Tier Tier 3 (non-preferred brand) Medication guide in member portal Florida Blue Medication Guide
Step Therapy Must try/fail ACE inhibitors or ARBs first Plan-specific formulary documents Formulary PDFs
Appeals Deadline 180 days from denial notice Appeals and grievances documentation Florida Blue Appeals Process

1. Verify Your Plan & Find the Right Forms

Before starting your Entresto prior authorization, confirm your specific Florida Blue plan type and access the correct forms:

Check Your Plan Details:

  • Log into your Florida Blue member portal using your member ID
  • Review your medication guide to confirm Entresto's formulary status
  • Note your specific plan name (ValueScript, CareChoices, etc.) as requirements may vary

Find Your Forms:

  • Most PA forms are accessible through the member portal after login
  • Provider-specific forms are available through the Availity platform in the Florida Blue Payer Space
  • Call the member services number on your ID card if you cannot locate the correct forms
Tip: Different Florida Blue products (commercial vs. Medicare Advantage) have different PA requirements. Always verify you're using the form that matches your specific plan type.

2. Prior Authorization Forms & Requirements

Step-by-Step: Fastest Path to Approval

  1. Your Doctor Initiates the Request
    • Physician calls 1-877-719-2583 or Prime Therapeutics at (800) 424-4947
    • Request the current Entresto PA form for your specific plan
    • Timeline: Same-day form access
  2. Gather Required Clinical Documentation
    • Heart failure diagnosis with LVEF documentation
    • Complete medication history showing ACE inhibitor or ARB trials
    • Evidence of failure, intolerance, or contraindications to preferred alternatives
    • Current dosing plan and treatment goals
    • Timeline: 1-2 business days to compile
  3. Submit Complete PA Request
    • Use Availity provider portal or fax to designated numbers
    • Include all supporting clinical notes and lab results
    • Timeline: Same-day submission possible
  4. Await Determination
    • Standard review: 7-14 business days
    • Expedited review (if urgent): 72 hours
    • You'll receive written notification of approval or denial

Clinician Corner: Medical Necessity Letter Checklist

When supporting your Entresto PA request, ensure your physician includes:

Essential Clinical Elements:

  • Diagnosis: Heart failure with reduced ejection fraction (HFrEF) with specific LVEF percentage
  • Prior Therapies: Documented trials of ACE inhibitors or ARBs with specific medications, doses, and duration
  • Treatment Outcomes: Reasons for discontinuation (inefficacy, side effects, contraindications)
  • Clinical Rationale: Why Entresto is medically necessary based on FDA labeling and heart failure guidelines
  • Monitoring Plan: How therapy will be monitored for safety and efficacy

Supporting Guidelines:

  • Reference ACC/AHA Heart Failure Guidelines
  • Cite FDA-approved indications for chronic heart failure
  • Include relevant clinical trial data (PARADIGM-HF) if applicable

3. Submission Portals & Electronic Access

Provider Portal Access

Availity Platform (for Healthcare Providers):

  • Access: Availity.com → Florida Blue Payer Space → Provider Portal
  • Requirements: Appropriate administrative role permissions set by Availity access administrator
  • Functions: Prior authorization requests, appeals, claims, specialty pharmacy coordination

Member Portal (for Patients):

  • Access: Florida Blue Member Portal
  • Functions: Track PA status, access medication guides, review coverage decisions
  • Login: Use member ID and password established during registration
Note: All prior authorization submissions for specialty medications like Entresto must go through secure, authenticated portals. No direct public URLs are available for PA submission.

4. Fax Numbers & Mailing Addresses

Key Contact Information

Prior Authorization Fax Numbers:

  • Standard Organization Determination: 1-904-301-1614
  • Expedited Appeals (urgent cases only): 1-305-437-7490

Appeals Mailing Address: Florida Blue Appeals and Grievances Department
P.O. Box 41629
Jacksonville, FL 32203-1629

Utilization Management Department: Florida Blue Utilization Management
4800 Deerwood Campus Parkway, Building 900, 5th Floor
Jacksonville, FL 32246

Cover Sheet Tips

When faxing PA requests or appeals:

  • Include patient name, member ID, and date of birth on every page
  • Reference specific medication (Entresto/sacubitril-valsartan)
  • Mark "URGENT" if requesting expedited review
  • Include provider NPI and contact information
  • Number all pages and include total page count

5. Specialty Pharmacy Setup

While Entresto is typically available at retail pharmacies, some Florida Blue plans may require specialty pharmacy dispensing for certain members.

If Specialty Pharmacy is Required:

  1. Provider Coordination: Your doctor will receive notification of specialty pharmacy requirement
  2. Patient Enrollment: Specialty pharmacy will contact you to set up delivery and monitoring
  3. Prescription Transfer: Existing prescriptions can be transferred from retail pharmacies
  4. Ongoing Support: Specialty pharmacies provide medication counseling and adherence monitoring

Common Specialty Pharmacy Partners:

  • Check your plan documents for contracted specialty pharmacy networks
  • Verify coverage before transferring prescriptions

6. Support Phone Lines & Contact Information

Member Services

Primary Member Line: 1-800-FLA-BLUE
General Appeals: 1-800-926-6565
TTY: 1-800-955-8770
Hours: 8:00 a.m. – 8:00 p.m. local time, seven days a week (October 1–March 31); Monday–Friday (April 1–September 30)

What to Ask When You Call:

  • "What is the status of my Entresto prior authorization request?"
  • "What specific clinical criteria must be met for Entresto approval?"
  • "Can you provide the current PA form for my plan?"
  • "What documentation is still needed for my request?"
  • "How do I request an expedited review?"

Provider Support

Provider Services: Contact through Availity platform or call member services for provider-specific issues Case Management: Available through the Utilization Management Department for complex cases

7. Florida Appeals & External Review Process

Internal Appeals Process

Timeline: 180 days from denial notice to file internal appeal

How to File:

  1. Written Appeal: Mail to appeals address listed above
  2. Phone: Call 1-800-926-6565 (for expedited appeals only)
  3. Fax: Use expedited fax number 1-305-437-7490 for urgent cases

Required Information:

  • Copy of denial letter
  • Additional clinical documentation supporting medical necessity
  • Physician letter explaining why Entresto is essential
  • Any new clinical information not included in original PA request

External Review (Florida Department of Financial Services)

If your internal appeal is denied, you can request an independent external review:

Contact Florida DFS:

  • Phone: 1-877-693-5236
  • Online: Submit complaint
  • Timeline: Must request within 4 months of final internal denial

External Review Process:

  • Independent medical experts review your case
  • Decision is binding on the insurance company
  • No cost to you for the external review
  • Timeline: Standard review within 45 days, expedited within 72 hours
From our advocates: We've seen cases where patients successfully overturned Entresto denials by providing comprehensive documentation of ACE inhibitor intolerance, even when initial PA requests were incomplete. The key was working with the cardiologist to document specific side effects and contraindications in detail, then submitting this through the formal appeals process rather than just resubmitting the original request.

8. When to Update Your Resources

Quarterly Updates Recommended:

  • Check for new PA forms or requirement changes
  • Review formulary updates (typically January 1 annually)
  • Verify contact numbers and portal access

Annual Reviews:

  • Confirm your plan hasn't changed PA requirements
  • Review any new clinical guidelines that might support coverage
  • Update provider portal access permissions if needed

Immediate Updates Needed When:

  • You receive a denial with new requirements
  • Your plan changes (job change, Medicare eligibility, etc.)
  • Florida Blue updates their PA policies

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documents
No heart failure diagnosis documented Submit complete cardiology records Echocardiogram, LVEF measurement, clinical notes
Step therapy not completed Document ACE inhibitor/ARB trials Medication history, side effect documentation, contraindication notes
Insufficient clinical justification Provide detailed medical necessity letter Physician attestation, treatment goals, monitoring plan
Missing prior authorization Resubmit complete PA request All required forms with clinical support

FAQ: Entresto Coverage with Florida Blue

Q: How long does Florida Blue prior authorization take for Entresto? A: Standard PA decisions are made within 7-14 business days. Expedited reviews (for urgent cases) are completed within 72 hours.

Q: What if Entresto isn't on my formulary? A: You can request a formulary exception by providing clinical documentation showing medical necessity and why preferred alternatives aren't appropriate.

Q: Can I get an expedited appeal if my doctor says it's urgent? A: Yes, if your physician documents that delays in treatment could seriously jeopardize your health, you can request expedited internal and external reviews.

Q: Does step therapy apply if I tried ACE inhibitors in another state? A: Yes, documented medication trials from any provider can count toward step therapy requirements. Ensure your new Florida physician has complete medication records.

Q: What happens if my appeal is denied? A: You can request an external review through Florida's Department of Financial Services, where independent medical experts make a binding decision.

Patient Assistance & Cost Support

If you're struggling with Entresto costs while navigating coverage issues:

Manufacturer Support:

  • Entresto Savings Program: Eligible patients may pay as little as $10 per month
  • Income-based assistance programs available

State Resources:

  • Florida pharmaceutical assistance programs
  • Community health center sliding fee scales

Foundation Support:

  • Patient advocate foundations may provide temporary assistance
  • Disease-specific foundations for heart failure patients

Counterforce Health: Streamlining Your Appeal Process

Navigating prior authorization denials and appeals can be overwhelming, especially when dealing with complex medications like Entresto. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to create point-by-point rebuttals aligned with each payer's specific requirements.

The platform specializes in identifying denial reasons—whether PA criteria, step therapy, non-formulary status, or "not medically necessary" determinations—and drafts comprehensive appeals using the right clinical evidence, FDA labeling, peer-reviewed studies, and recognized drug compendia. For patients facing Florida Blue denials, this systematic approach can significantly improve appeal success rates while reducing the administrative burden on healthcare providers.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and requirements can change. Always verify current information with your insurance plan and healthcare provider. For specific coverage questions, contact Florida Blue directly using the numbers provided above.

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