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

How to Get Entresto (sacubitril/valsartan) Covered by Cigna in Illinois: Prior Authorization, Appeals, and Cost Savings

Answer Box: Getting Entresto Covered by Cigna in Illinois

Entresto (sacubitril/valsartan) requires prior authorization from Cigna and typically involves step therapy—you must try a generic ACE inhibitor or ARB first. In Illinois, if denied, you have 180 days for internal appeals and 30 days for external review after final denial. The fastest path: gather heart failure diagnosis, LVEF results, and prior medication trials, then submit through Cigna's provider portal. Commercial insurance patients may qualify for Novartis's $10 copay card (up to $4,100/year).

First step today: Call your doctor's office to confirm they have your complete heart failure records and prior ACE inhibitor/ARB trial documentation ready for the prior authorization request.

Table of Contents

What Drives Entresto Costs with Cigna

Understanding your Cigna plan's structure helps predict Entresto's out-of-pocket cost and approval requirements. Most Cigna plans place Entresto on Tier 3 (non-preferred brand) or Tier 4 (specialty), resulting in higher copayments or coinsurance compared to generic medications.

Key Cost Factors

Formulary Tier: Entresto typically appears as a non-preferred brand drug, often requiring 30-50% coinsurance after deductible rather than a flat copay.

Prior Authorization: Required for all Cigna plans, adding administrative steps but not direct costs.

Step Therapy: You must try and fail (or show intolerance to) a generic ACE inhibitor or ARB before Entresto approval.

Specialty Designation: Some Cigna plans require Entresto dispensing through Accredo specialty pharmacy, which may limit your pharmacy choices but doesn't typically change the tier-based cost.

Tip: Your exact tier and cost-sharing depend on your specific Cigna plan. The same medication can have different requirements across Cigna's various products.

Investigating Your Cigna Benefits

Before starting the prior authorization process, gather key information about your specific coverage.

What to Ask Cigna Customer Service

Call the number on your insurance card and ask:

  • "Is Entresto covered on my formulary, and what tier?"
  • "What's my copay or coinsurance for Tier 3/4 medications?"
  • "Do I have a separate specialty drug deductible?"
  • "Is prior authorization required, and are there step therapy requirements?"
  • "Must I use Accredo, or can I fill at retail pharmacies?"

Information to Record

Document the representative's name, date, and reference number. Ask for written confirmation of coverage details, especially if you receive conflicting information.

Key details to confirm:

  • Annual deductible amount and how much you've met
  • Out-of-pocket maximum and current spending
  • Whether your plan covers 30-day vs. 90-day supplies
  • Mail-order pharmacy options and any cost differences

Prior Authorization Requirements

Cigna requires prior authorization for Entresto across all plan types. The approval process focuses on medical necessity and step therapy compliance.

Required Documentation

Your healthcare provider must submit:

Clinical Information:

  • Heart failure diagnosis with ICD-10 code (typically I50.22 for chronic systolic heart failure)
  • Current left ventricular ejection fraction (LVEF) measurement
  • NYHA functional class and symptom documentation
  • Treatment goals and expected outcomes

Medication History:

  • Detailed record of ACE inhibitor trials (drug name, dose, duration, reason for discontinuation)
  • If ACE inhibitors are contraindicated, documentation of ARB trial
  • Evidence of failure, inadequate response, or intolerance to step therapy requirements

Administrative Details:

  • Completed prior authorization form with correct NDC codes
  • Provider NPI number and patient insurance information
  • Prescriber attestation of medical necessity

Submission Process

Provider Portal: Most efficient method for submission and tracking Fax: Available as backup (verify current fax number with Cigna) Phone: For urgent requests or technical issues

Timeline: Non-urgent requests receive decisions within 72 hours; urgent (exigent) requests within 24 hours.

Assistance Options and Cost Savings

Multiple programs can reduce Entresto's out-of-pocket costs, depending on your insurance type and financial situation.

Manufacturer Copay Assistance

Entresto $10 Copay Card

  • Eligibility: Commercial insurance only (not Medicare, Medicaid, or other government programs)
  • Benefit: Pay as little as $10 per 30-, 60-, or 90-day supply
  • Annual limit: Up to $4,100 in savings per year
  • Enrollment: Call 1-888-368-7378, visit entresto.com, or text SIGNUP to 470-264-9643
Note: The copay card works at most retail pharmacies and can be combined with mail-order prescriptions. For mail-order, you may need to pay full price initially and submit a rebate form.

Patient Assistance Foundation

Novartis Patient Assistance Foundation (NPAF)

  • Eligibility: Uninsured or underinsured patients meeting income guidelines
  • Benefit: Free medication for qualifying patients
  • Application: Call 1-800-277-2254 or visit pap.novartis.com
  • Documentation: Proof of income, lack of prescription coverage, and medical necessity

Important: The Novartis Patient Assistance Program for Entresto will end in 2026. Patients should explore alternative medications or assistance options as this date approaches.

Additional Support Options

30-Day Free Trial: One-time offer for any patient, regardless of insurance status. Call 1-888-368-7378.

Simplefill Advocacy: Helps navigate assistance programs and applications. Call 1-877-386-0206.

Step Therapy and Formulary Exceptions

Cigna's step therapy policy requires trying less expensive alternatives before approving Entresto. Understanding these requirements helps avoid delays and denials.

Standard Step Therapy Requirements

Step 1: Generic ACE inhibitor (e.g., lisinopril, enalapril) or ARB (e.g., losartan, valsartan) Step 2: Entresto approval after documented failure or intolerance of Step 1 medications

Requesting Step Therapy Override

You can request an exception if:

  • Previous ACE inhibitor/ARB caused intolerance or adverse reactions
  • Medical contraindications prevent use of step therapy medications
  • You've already completed step therapy with another insurer
  • Clinical urgency requires immediate Entresto initiation

Required Documentation for Override:

  • Provider letter explaining medical necessity for bypassing step therapy
  • Clinical notes documenting contraindications or previous failures
  • Supporting evidence from medical literature if applicable
  • Clear timeline of previous medication trials and outcomes

Pharmacy Choice: Accredo vs. Retail

Cigna may require specialty medications to be dispensed through Accredo, their exclusive specialty pharmacy network. This doesn't change your cost-sharing but affects where you can fill prescriptions.

When Accredo is Required

If your formulary shows "SP" (Specialty Medication) designation for Entresto, you must use Accredo for:

  • Home delivery (most common)
  • Direct shipment to your healthcare provider's office

Coordination Tips

Before First Fill:

  • Confirm whether your plan requires Accredo or allows retail pharmacy
  • Set up Accredo account if required (they'll contact you after PA approval)
  • Verify your preferred delivery address and contact information

Ongoing Management:

  • Accredo provides refill reminders and medication counseling
  • 90-day supplies are standard, reducing refill frequency
  • Coordinate with your provider for any dosing changes or side effect management
Tip: If you prefer retail pharmacy convenience, ask your doctor if there are therapeutically equivalent alternatives not designated as specialty medications.

Appeals Process in Illinois

Illinois provides robust patient rights for insurance denials, including internal appeals and independent external review.

Internal Appeals with Cigna

Timeline: Submit within 180 days of denial Process: Written appeal with supporting documentation Decision: Cigna responds within 30 days for prior authorization denials

Required Documents:

  • Original denial letter or EOB
  • Provider letter of medical necessity
  • Updated clinical documentation
  • Any new supporting evidence (lab results, imaging, specialist consultation)

External Review in Illinois

If Cigna denies your internal appeal, Illinois law guarantees independent external review through the Health Carrier External Review Act.

Key Details:

  • Deadline: 30 days from final internal denial (shorter than many states)
  • Process: Independent Review Organization (IRO) with board-certified physician expertise
  • Timeline: Decision within 5 business days after IRO receives all materials
  • Cost: Free to consumers; insurers pay review fees
  • Decision: Binding on the insurance company

How to Request:

  • Use forms from Illinois Department of Insurance website
  • Submit to both Cigna and the state
  • Include all medical records and supporting documentation

Illinois Resources for Help

Illinois Department of Insurance Office of Consumer Health Insurance (OCHI)

  • Toll-free hotline: 877-527-9431
  • Assists with appeals and external review applications
  • Can answer questions about your rights under Illinois law

Illinois Attorney General Health Care Bureau

  • Health Care Helpline: 1-877-305-5145
  • Can intervene informally with insurers
  • Helps with complex cases requiring additional advocacy

Planning for Annual Renewals

Cigna plan benefits can change annually, affecting Entresto coverage and costs. Planning ahead prevents coverage gaps.

What Can Change Year to Year

Formulary Status: Entresto might move to a different tier or be removed entirely Prior Authorization Requirements: Criteria may become more or less restrictive Step Therapy: Requirements might change or expand to include additional medications Pharmacy Networks: Accredo requirements or retail options may be modified

Renewal Preparation Checklist

By November (Open Enrollment):

  • Review next year's formulary for Entresto coverage
  • Compare tier placement and estimated costs
  • Confirm your providers accept the plan
  • Check if Accredo requirements continue

By December:

  • If switching plans, ensure new coverage begins January 1
  • Request 90-day supply to bridge any coverage gaps
  • Transfer prior authorization documentation to new plan if needed

January:

  • Verify new insurance cards and member information
  • Confirm Entresto remains covered under new plan year
  • Update pharmacy and provider records with new insurance details

Scripts for Key Conversations

Having prepared talking points helps navigate complex insurance conversations more effectively.

Calling Cigna Customer Service

"Hi, I'm calling about prior authorization for Entresto, generic name sacubitril/valsartan. My member ID is [number]. I need to understand the step therapy requirements and what documentation my doctor needs to submit. Can you also confirm if this needs to go through Accredo specialty pharmacy?"

Follow-up questions:

  • "What specific ACE inhibitor or ARB do I need to try first?"
  • "How long do I need to be on the step therapy medication?"
  • "Can you email me the prior authorization form and requirements?"

Provider Office Conversation

"I need Entresto for my heart failure, but Cigna requires prior authorization and step therapy. Do you have documentation of my previous ACE inhibitor trials? If not, what's the fastest way to complete the step therapy requirement while minimizing any gap in my heart failure treatment?"

Pharmacy Consultation

"My doctor prescribed Entresto, and I have Cigna insurance. Can you check if this needs to go through Accredo specialty pharmacy or if you can fill it here? Also, I have a manufacturer copay card—can you verify it will work with my insurance?"

FAQ

How long does Cigna prior authorization take for Entresto in Illinois? Standard requests receive decisions within 72 hours. Urgent requests are processed within 24 hours. Your provider can request expedited review if delay would harm your health.

What if Entresto isn't on my Cigna formulary? You can request a formulary exception with your provider's support. This requires demonstrating medical necessity and often showing that formulary alternatives are inappropriate for your condition.

Can I appeal if I've tried step therapy with a different insurer? Yes. Cigna should honor previous step therapy trials if properly documented. Your provider needs to submit records showing the medication trials, durations, and reasons for discontinuation.

Does Illinois have special protections for heart failure medications? Illinois follows standard insurance regulations but provides strong appeal rights. The state's external review process is faster than many states (5 business days) and includes physician reviewers with relevant expertise.

What happens if my Cigna plan changes at renewal? New plan years can change formulary status, tier placement, and prior authorization requirements. Review your new plan's formulary by December and work with your provider to ensure continued coverage.

Can I use GoodRx or other discount programs with Cigna? Generally no—you can't combine insurance benefits with discount programs. However, if Cigna doesn't cover Entresto or you haven't met your deductible, cash-pay discount programs might be an option.

How do I know if I need Accredo specialty pharmacy? Check your formulary for "SP" designation next to Entresto, or call Cigna customer service. If required, Accredo will contact you directly after prior authorization approval.

What if I can't afford Entresto even with insurance? Apply for the Novartis Patient Assistance Foundation if you meet income guidelines. The $10 copay card helps commercial insurance patients, and the 30-day free trial provides immediate relief while exploring long-term options.

When navigating complex insurance coverage, having expert support can make the difference between approval and denial. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies, then drafts point-by-point rebuttals aligned to each payer's specific requirements, increasing your chances of successful coverage.

Remember: this guide provides general information and isn't medical advice. Always consult your healthcare provider about treatment decisions and work with them on insurance-related documentation.

Sources & Further Reading

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