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

How to Get Entresto (sacubitril/valsartan) Covered by Blue Cross Blue Shield in Virginia: PA Forms, Appeal Scripts & State Protections

Quick Answer: Getting Entresto Covered in Virginia

Entresto (sacubitril/valsartan) is covered by Blue Cross Blue Shield Virginia (Anthem) but requires prior authorization. Your fastest path to approval: (1) Have your doctor submit a PA request with heart failure diagnosis, ejection fraction data, and documentation of ACE inhibitor trial/failure, (2) Use Virginia's step therapy exception laws if denied for missing prior therapies, (3) Appeal within 120 days citing medical necessity if initially rejected. Start by calling the Pharmacy Member Services number on your insurance card today.

Table of Contents

  1. Why Virginia State Rules Matter for Your Coverage
  2. Prior Authorization Requirements & Turnaround Standards
  3. Step Therapy Protections in Virginia
  4. Continuity of Care During Coverage Transitions
  5. External Review & Complaint Process
  6. Practical Scripts for Calls and Appeals
  7. Coverage Limitations & ERISA Plans
  8. Quick Reference: Forms and Contacts

Why Virginia State Rules Matter for Your Coverage

Virginia's insurance laws provide crucial protections that work alongside your Blue Cross Blue Shield plan policies. While your plan determines formulary placement and coverage criteria, Virginia law sets minimum standards for appeal timelines, step therapy exceptions, and external review rights.

Key Virginia protections include:

  • Mandatory 72-hour turnaround for non-urgent prior authorization decisions
  • Medical exception rights for step therapy requirements
  • 120-day window for external review appeals
  • Continuity of care protections during plan transitions

These protections apply to most commercial Blue Cross Blue Shield plans in Virginia, though self-funded employer plans (ERISA) may have different rules.

Note: Anthem Blue Cross Blue Shield holds about 43% of Virginia's commercial insurance market, making these state protections particularly relevant for many patients.

Prior Authorization Requirements & Turnaround Standards

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Doctor must submit request before coverage Anthem VA Drug List Plan formulary
Formulary Tier Standard coverage, varies by plan Member portal or formulary PDF Plan documents
Step Therapy May require ACE/ARB trial first PA criteria or denial letter Clinical policy
Quantity Limits Typically 30-60 tablets per month Pharmacy or member services Plan limits

Turnaround Standards

Virginia law requires:

  • Non-urgent requests: 72 hours maximum for decision
  • Urgent/expedited: 24 hours for life-threatening situations
  • Renewals: Must be processed before current authorization expires

Counterforce Health helps streamline this process by automatically identifying denial reasons and drafting targeted appeals with the right clinical evidence and payer-specific requirements.

Step Therapy Protections in Virginia

Virginia Code § 38.2-3407.9:05 provides strong step therapy exception rights. Your doctor can request an override if:

  1. The required step therapy drug is contraindicated
  2. The drug would be ineffective based on your clinical characteristics
  3. You previously discontinued the required drug due to lack of efficacy or adverse events
  4. You're currently stable on the requested drug

Documentation Requirements

Your prescriber must submit written justification with:

  • Clinical rationale for the exception
  • Supporting documentation (chart notes, lab results, adverse event records)
  • Reference to the specific Virginia statute

Timeline: Plans must respond within 72 hours for standard requests, 24 hours for urgent cases.

Tip: Drug samples don't count as evidence of trying a preferred therapy. Only documented prescriptions with adequate trial periods qualify.

Continuity of Care During Coverage Transitions

Virginia protects patients during coverage changes through:

Grace Periods & Transition Fills

  • Temporary supplies (usually 30 days) when formularies change
  • Ongoing coverage for chronic conditions during plan transitions
  • Exception request processes for discontinued medications

Chronic Condition Protections

For heart failure patients, Virginia requires insurers to:

  • Maintain coverage during reasonable transition periods
  • Provide clear exception request processes
  • Offer expedited appeals for medically necessary drugs

Action step: If facing a plan change, contact your insurer early to confirm Entresto coverage and request transition supplies if needed.

External Review & Complaint Process

When Internal Appeals Fail

Virginia's State Corporation Commission Bureau of Insurance oversees external review for medical necessity denials.

Eligibility: Denials based on medical necessity, appropriateness, or experimental treatment determination

Timeline: File within 120 days of final internal denial

Required Forms & Process

  1. Form 216-A: External Review Request (required for all cases)
  2. Form 216-B: If someone files on your behalf
  3. Form 216-C: For expedited review (urgent cases)

Submit to:

  • Email: [email protected]
  • Fax: (804) 371-9915
  • Mail: SCC Bureau of Insurance – External Review, P.O. Box 1157, Richmond, VA 23218

Decision timeline:

  • Standard review: 45 days
  • Expedited review: 72 hours

Required Documentation

  • Completed request form
  • Copy of insurance card
  • Final denial letter from Blue Cross Blue Shield
  • Medical records release form
  • Supporting clinical documentation
From our advocates: We've seen patients succeed in external review by including recent hospitalization records, ejection fraction measurements, and clear documentation of ACE inhibitor intolerance. The independent reviewers often have more clinical flexibility than internal utilization management teams.

Practical Scripts for Calls and Appeals

Patient Phone Script for Blue Cross Blue Shield

"Hi, I'm calling about prior authorization for Entresto, generic name sacubitril-valsartan, for my heart failure. My member ID is [number]. Can you tell me the specific clinical criteria required and provide the PA form? I'd also like to know if step therapy applies and what Virginia's step therapy exception process requires."

Medical Necessity Appeal Template

"This appeal requests coverage for Entresto (sacubitril/valsartan) for [patient name] with chronic heart failure and reduced ejection fraction of [%]. Per Virginia Code § 38.2-3407.9:05, we request a step therapy exception based on [contraindication/prior failure/current stability]. Supporting documentation includes [list specific items]. This medication is medically necessary per FDA labeling and current heart failure guidelines."

Peer-to-Peer Request Script

"I'm requesting a peer-to-peer review for Entresto denial. The patient has symptomatic heart failure with EF of [%], has failed/cannot tolerate [specific ACE/ARB], and meets FDA criteria. I'm available [times] to discuss the clinical rationale with your medical director."

Coverage Limitations & ERISA Plans

Self-Funded Plan Differences

Many large employers in Virginia use self-funded plans governed by federal ERISA law, which may limit state protections:

  • Virginia step therapy laws may not apply
  • External review may go through federal process instead of state
  • Appeal timelines follow federal rather than state requirements

How to identify: Look for "administered by" rather than "insured by" on your card, or ask HR about plan funding.

What Still Applies

Even ERISA plans must provide:

  • Clear appeal processes
  • Medical necessity review standards
  • Access to external review (federal system)

Quick Reference: Forms and Contacts

Essential Contacts

Blue Cross Blue Shield Virginia (Anthem):

Virginia Bureau of Insurance:

Managed Care Ombudsman:

  • Same number: 1-877-310-6560
  • Helps with HMO and managed care issues

Key Forms Checklist

Before Starting:

  • ✓ Insurance card and member ID
  • ✓ Prescriber contact information
  • ✓ Heart failure diagnosis and ejection fraction
  • ✓ List of prior ACE inhibitors/ARBs tried
  • ✓ Documentation of adverse reactions or failures
  • ✓ Recent hospitalization records (if applicable)

For Appeals:

  • ✓ Original denial letter
  • ✓ Medical records supporting medical necessity
  • ✓ Prescriber attestation letter
  • ✓ Virginia step therapy exception documentation (if applicable)

Frequently Asked Questions

How long does Blue Cross Blue Shield PA take in Virginia? Virginia law requires decisions within 72 hours for standard requests, 24 hours for urgent cases. Plans often respond faster.

What if Entresto isn't on my formulary? Request a formulary exception with medical necessity documentation. Your doctor must show why covered alternatives won't work.

Can I get expedited appeals? Yes, if delay would seriously jeopardize your health. Your doctor must certify urgency using Form 216-C for external review.

Does step therapy apply if I failed therapies outside Virginia? Yes, documented failures from any state count toward Virginia step therapy exception criteria.

What's the cost without insurance? Entresto typically costs several hundred dollars monthly. Check the manufacturer's copay card program for commercial insurance patients.

When should I contact the state regulator? If Blue Cross Blue Shield violates appeal timelines, denies coverage without clear rationale, or doesn't follow Virginia's step therapy exception laws.

Costs & Financial Support

Manufacturer Support:

  • Copay card may reduce costs to $10 per month for commercially insured patients
  • Does not apply to Medicare, Medicaid, or government programs
  • Entresto Financial Support

State Resources:

  • Virginia Poverty Law Center Health Assistance program
  • Bureau of Insurance consumer guidance (free)

Counterforce Health specializes in turning insurance denials into successful appeals by identifying the specific denial basis and drafting evidence-backed rebuttals aligned to each payer's own rules. The platform pulls the right clinical citations and weaves them into appeals that meet procedural requirements while tracking deadlines and required documentation.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always verify current requirements with your specific Blue Cross Blue Shield plan and consult healthcare providers for medical decisions. For official guidance on Virginia insurance regulations, contact the State Corporation Commission Bureau of Insurance.

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