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

How to Get Entresto (Sacubitril/Valsartan) Covered by Cigna in Georgia: Prior Authorization Forms, Appeals, and Step-by-Step Guide

Answer Box: Getting Entresto Covered by Cigna in Georgia

Eligibility: Cigna covers Entresto for chronic heart failure with reduced ejection fraction after documented ACE inhibitor or ARB trial failure. Fastest approval path: Submit prior authorization with heart failure diagnosis (ICD-10 I50.22), current LVEF measurement, and detailed ACE inhibitor/ARB trial documentation. First step today: Call your cardiologist to request prior authorization submission and verify your plan's step therapy requirements. Georgia residents have 60 days after final denial to request external review through the Georgia Department of Insurance.

Table of Contents

Plan Types & Network Requirements

Cigna's coverage for Entresto varies significantly by plan type, affecting both referral requirements and approval pathways.

HMO Plans require a Primary Care Provider (PCP) referral before seeing a cardiologist. Your PCP must provide written referral documentation and note it in your medical record. Only in-network providers are covered at the highest benefit level.

PPO Plans don't require referrals to see cardiologists, giving you direct access to specialists. However, precertification may still be required for certain services, including specialty medications like Entresto.

EPO Plans also don't require referrals but limit out-of-network coverage to medical emergencies only. Check your ID card for referral requirements - it will clearly indicate if referrals are needed.

Formulary Status & Tier Placement

Entresto appears on multiple Cigna Healthcare comprehensive drug lists, indicating coverage across various plan types. However, specific tier placement varies by plan design.

Cigna uses different tier structures:

  • 4-tier plans: Tier 1 (Generic), Tier 2 (Preferred Brand), Tier 3 (Non-Preferred), Tier 4 (Specialty)
  • 5-6 tier plans: Additional tiers for preferred generics and select diabetic drugs
Note: Tier placement affects your out-of-pocket costs significantly. Contact Cigna member services or check your plan's formulary to confirm Entresto's tier placement for your specific plan.

Prior Authorization & Step Therapy Rules

Cigna requires a structured approach for Entresto coverage. The step therapy process requires trying generic sacubitril-valsartan tablets first, followed by brand-name Entresto if Step 1 criteria are met.

Required Documentation

Your physician must document:

  • ACE inhibitor or ARB trial: Drug name, dose, duration, and reason for discontinuation
  • Heart failure diagnosis: ICD-10 code I50.22 with current LVEF measurement
  • Clinical rationale: Why previous therapy failed or caused intolerance
  • Contraindications: Any medical reasons preventing use of alternative medications

All Entresto approvals through Cigna are provided for a 1-year duration.

Specialty Pharmacy Requirements

Many Cigna plans require specialty medications like Entresto to be filled through Accredo Specialty Pharmacy for coverage.

Patient Enrollment Process

  1. Call Accredo at 877-826-7657 (Monday-Friday 7:00 am-10:00 pm CST, Saturday 7:00 am-4:00 pm CST)
  2. Have ready: insurance ID card, doctor's contact information, medication name
  3. A patient care advocate will help schedule delivery

Fulfillment Timeline

  • New prescriptions: 5-7 days (includes 2-3 days for delivery scheduling)
  • Refills: 24-48 hours

Some plans allow one or more fills at retail pharmacy before requiring Accredo, so verify your plan's specific requirements.

Step-by-Step: Fastest Path to Approval

Coverage at a Glance

Requirement What it means Where to find it Source
PA needed? Prior authorization required Plan formulary or member portal Cigna formulary documents
Step therapy Try ACE inhibitor/ARB first Coverage policy Cigna step therapy criteria
Specialty pharmacy May require Accredo Plan materials Cigna specialty pharmacy guide
Appeals deadline 60 days in Georgia Georgia DOI Georgia external review process

The 7-Step Process

  1. Verify coverage (Patient/Clinic): Log into myCigna app or call member services to confirm Entresto is covered and identify any restrictions.
  2. Gather documentation (Clinic): Collect heart failure diagnosis, LVEF results, and detailed records of ACE inhibitor/ARB trials with outcomes.
  3. Submit prior authorization (Clinic): Complete Cigna's PA form with all required clinical documentation. Exception requests are typically reviewed within 72 hours.
  4. Enroll with specialty pharmacy (Patient): If approved, call Accredo at 877-826-7657 to set up prescription fulfillment.
  5. Monitor approval status (Patient/Clinic): Track through provider portal or member services.
  6. Appeal if denied (Clinic): Submit internal appeal with additional clinical evidence within Cigna's appeal timeframes.
  7. Request external review (Patient): If internal appeals fail, file with Georgia DOI within 60 days of final denial.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
No HF diagnosis documented Provide clear diagnosis with ICD-10 Current LVEF measurement, echo report, clinical notes
ACE inhibitor not tried Document previous trial Drug name, dose, duration, reason for discontinuation
Concomitant ACE inhibitor use Confirm medication list Current medication reconciliation, washout period documentation
Lack of medical necessity Strengthen clinical rationale Guidelines citations, symptom severity, treatment goals

Appeals Process for Georgia Residents

Georgia residents have specific rights when appealing insurance denials, governed by the Georgia Healthcare Consumer's Utility and Billing Appeals Act.

Internal Appeals with Cigna

You or your healthcare provider can request a review of prior authorization decisions. Cigna typically has 180 days for internal appeal windows, with expedited reviews available for urgent situations.

Georgia External Review Process

If internal appeals fail, Georgia law provides an independent external review option:

Timeline: You have 60 days from your final denial letter to request external review through the Georgia Department of Insurance.

Process:

  1. Submit application to GA Office of Commissioner of Insurance and Fire Safety
  2. Georgia DOI reviews eligibility and assigns independent review organization
  3. Decision rendered within 30 business days (72 hours for expedited reviews)

Cost: External review is free for consumers in Georgia.

Contact: Georgia DOI Consumer Services: 1-800-656-2298

Important: The external reviewer's decision is binding on Cigna and required by Georgia law to be accepted.

Cost-Share Basics

Your out-of-pocket costs depend on several factors:

  • Deductible: Amount you pay before insurance coverage begins
  • Copay/Coinsurance: Your share after deductible is met
  • Tier placement: Higher tiers typically mean higher costs
  • Specialty pharmacy: May have different cost-sharing than retail
Note: This information is educational only. Consult your plan materials for specific cost-sharing details.

Clinician Corner: Medical Necessity Documentation

Medical Necessity Letter Checklist

When submitting prior authorization, include:

Clinical Problem:

  • Heart failure diagnosis with NYHA class
  • Current LVEF measurement and date
  • Symptom severity and functional status

Prior Treatments:

  • Specific ACE inhibitor or ARB tried
  • Dose, duration, and clinical response
  • Reason for discontinuation (efficacy vs. tolerability)

Clinical Rationale:

  • Why Entresto is medically necessary
  • Expected clinical benefits
  • Treatment goals and monitoring plan

Guideline Support:

  • FDA labeling for Entresto (verify with source)
  • ACC/AHA Heart Failure Guidelines citations
  • Relevant clinical studies supporting use

Counterforce Health helps streamline this process by automatically generating evidence-backed appeals that align with payer-specific requirements, pulling the right clinical citations and formatting them according to Cigna's preferred documentation standards.

When to Escalate in Georgia

If you've exhausted internal appeals and external review options, additional escalation paths include:

Georgia Department of Insurance: File a complaint if you believe Cigna violated state insurance laws or regulations. Contact Consumer Services at 1-800-656-2298.

Georgians for a Healthy Future: This nonprofit provides consumer assistance and can help navigate the appeals process or refer to legal aid when appropriate.

Legal Consultation: For complex cases or suspected bad faith denials, consider consulting with an attorney specializing in insurance law.

FAQ

How long does Cigna prior authorization take in Georgia? Non-urgent requests are typically completed within 72 hours. Expedited reviews for urgent conditions are processed faster.

What if Entresto is non-formulary on my plan? You can request a formulary exception through Cigna's exception process. Your physician must provide clinical justification for why formulary alternatives are inappropriate.

Can I request an expedited appeal in Georgia? Yes, both Cigna and Georgia's external review process offer expedited pathways when delays could seriously jeopardize your health.

Does step therapy apply if I tried ACE inhibitors outside Georgia? Yes, previous trials from any location count toward step therapy requirements, provided you have adequate documentation.

What happens if I switch from retail to Accredo mid-treatment? Accredo will coordinate the transfer and ensure continuity of therapy. New patient setup takes 5-7 days.

Can I appeal if my doctor won't submit prior authorization? You can request prior authorization directly through Cigna member services, though clinical documentation from your physician will still be required.

Counterforce Health specializes in turning insurance denials into successful appeals by automatically generating targeted, evidence-backed rebuttals that align with each payer's specific requirements. The platform analyzes denial letters, identifies the exact coverage criteria, and drafts point-by-point responses using the right clinical evidence - from FDA labeling to peer-reviewed studies - formatted according to payer preferences like Cigna's documentation standards. For patients and clinicians dealing with complex prior authorization requirements, Counterforce Health streamlines the appeals process and improves approval rates.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and requirements may change. Always verify current requirements with Cigna and consult your healthcare provider for medical decisions. For official appeals guidance in Georgia, contact the Georgia Department of Insurance Consumer Services at 1-800-656-2298.

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