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

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

Answer Box: Your Fastest Path to Entresto Coverage in New York

Cigna requires prior authorization for Entresto (sacubitril/valsartan) through Express Scripts. Submit your PA request with heart failure diagnosis (ICD-10 I50.22), LVEF results, and documented ACE inhibitor/ARB trial failure. If denied, you have 180 days for internal appeal, then 4 months for New York's binding external review through the Department of Financial Services. Call Accredo Specialty Pharmacy at 877-826-7657 to enroll once approved.

First step today: Verify your PA status at myCigna.com or call the number on your ID card.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Prior Authorization Forms and Submission
  4. Specialty Pharmacy Enrollment with Accredo
  5. Appeals Process: Internal and External Review
  6. Common Denial Reasons and How to Fix Them
  7. New York External Review Rights
  8. Cost Savings and Patient Assistance
  9. FAQ: Your Most Common Questions
  10. Sources and Further Reading

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all Cigna plans Cigna PA Policy
Formulary Status Typically Tier 3-4 specialty Check myCigna.com drug list
Step Therapy Must try ACE inhibitor or ARB first Cigna Step Therapy Policy
Specialty Pharmacy Accredo required for most plans Cigna Specialty Pharmacy Guide
Diagnosis Requirement Heart failure with reduced LVEF ICD-10 code I50.22

Step-by-Step: Fastest Path to Approval

1. Verify Your Coverage Requirements

Who: You or your clinic staff
Action: Log into myCigna.com or call member services
Timeline: 5 minutes
What to check: PA status, formulary tier, step therapy requirements

2. Gather Required Documentation

Who: Your cardiologist's office
Documents needed:

  • Heart failure diagnosis with ICD-10 code I50.22
  • Echocardiogram results showing LVEF
  • NYHA functional class (if available)
  • Documentation of ACE inhibitor or ARB trial with specific drug, dose, duration, and reason for discontinuation

3. Submit Prior Authorization

Who: Your prescribing physician
Methods:

  • Electronic: CoverMyMeds, Surescripts, or EviCore portals
  • Fax: 1-866-873-8279
  • Phone: 1-800-882-4462
  • Online: CignaForHCP.com
    Timeline: 72 hours standard, 24 hours expedited

4. Enroll with Accredo Specialty Pharmacy

Who: You (after PA approval)
Contact: 877-826-7657
Hours: Mon-Fri 7am-10pm CST, Sat 7am-4pm CST
What to have ready: Insurance ID, doctor's contact info, prescription details

5. Monitor and Follow Up

Timeline: Check status after 3 business days
If denied: File internal appeal within 180 days

Prior Authorization Forms and Submission

Required Documentation for PA Request

Your physician must include these elements in the prior authorization submission:

  • Heart failure diagnosis with ICD-10 code I50.22 (Chronic systolic heart failure)
  • Quantitative LVEF value from echocardiogram with date and facility
  • NYHA functional class (Class I-IV if available)
  • Medication history documenting ACE inhibitor or ARB trial with specific drug, dose, duration, and reason for discontinuation
  • Current symptoms and functional status

Submission Methods

Electronic Prior Authorization (Preferred):

Traditional Methods:

  • Fax: 1-866-873-8279
  • Phone: 1-800-882-4462
Tip: Electronic submissions typically process faster and provide real-time status updates.

Processing Timelines

  • Standard review: 72 hours
  • Expedited review: 24 hours for urgent circumstances
  • Auto-approval: If Cigna doesn't respond within these timeframes, the request is automatically approved

Specialty Pharmacy Enrollment with Accredo

Most Cigna plans require Entresto to be filled through Accredo Specialty Pharmacy for coverage.

Enrollment Process

Call Accredo at 877-826-7657 with:

  • Your Cigna insurance ID card
  • Prescribing physician's contact information
  • Prescription details (strength, quantity)

What to Expect

  1. Account setup: Create online account at MyAccredoPatients.com
  2. Prescription transfer: Accredo coordinates with your current pharmacy
  3. Delivery scheduling: Home or office delivery options
  4. Clinical support: Pharmacist counseling and medication management

Timelines

  • New prescriptions: 5-7 days (including 2-3 days delivery)
  • Refills: 24-48 hours
  • Standard supply: 90-day fills
Note: Request a 90-day supply to minimize refill frequency and potential gaps in therapy.

Appeals Process: Internal and External Review

Internal Appeal with Cigna

If your PA is denied, you have 180 days from the denial notice to file an internal appeal.

Required documents:

Submission methods:

  • Online: myCigna portal
  • Phone: 1-800-244-6224
  • Mail: Address provided in denial letter

Expedited Internal Appeals

Available when your health is at serious risk. Decisions issued within 72 hours.

New York External Review Rights

New York residents have strong appeal rights through the Department of Financial Services (DFS).

When to File External Review

  • After receiving Cigna's final adverse determination on internal appeal
  • Denial based on medical necessity or experimental/investigational status
  • Deadline: 4 months from Cigna's final denial

How to File

  1. Download the form: New York State External Appeal Application
  2. Complete with supporting documents: Medical records, clinical evidence, prescriber letters
  3. Submit: Mail to DFS, 99 Washington Avenue, Box 177, Albany, NY 12210, or fax (800) 332-2729

Review Timelines

  • Standard: 30 days
  • Expedited: 72 hours
  • Urgent drug denials: 24 hours

Cost and Support

  • Fee: $25 (waived for financial hardship or Medicaid enrollees)
  • Free assistance: Community Health Advocates at 888-614-5400
  • DFS Consumer Helpline: 1-800-342-3736
Success Rate: New York's external review program has high overturn rates when strong clinical evidence supports FDA-approved uses.

Common Denial Reasons and How to Fix Them

Denial Reason How to Overturn
No heart failure diagnosis documented Submit echocardiogram with LVEF results and ICD-10 code I50.22
Concomitant ACE inhibitor use Provide documentation of ACE inhibitor discontinuation with washout period
Lack of step therapy compliance Document specific ACE inhibitor or ARB tried, dose, duration, and reason for failure/intolerance
Quantity limits exceeded Request quantity limit exception with clinical justification for prescribed dose
"Not medically necessary" Submit peer-reviewed studies, FDA labeling, and heart failure guidelines supporting use

Clinician Corner: Medical Necessity Letter Checklist

When writing a medical necessity letter, include:

  • Problem statement: Patient's heart failure severity and functional status
  • Prior treatments: Specific ACE inhibitors/ARBs tried with doses, duration, and outcomes
  • Clinical rationale: Why Entresto is necessary based on current guidelines
  • Guideline citations: Reference AHA/ACC Heart Failure Guidelines and FDA labeling
  • Monitoring plan: How you'll assess response and manage potential side effects

Cost Savings and Patient Assistance

Manufacturer Support

Novartis Patient Assistance: Visit the Novartis patient support website (verify current programs and eligibility)

Additional Resources

  • State pharmaceutical assistance programs: Check New York State Department of Health website
  • Foundation grants: Research disease-specific foundations that may assist with heart failure medications
  • Pharmacy discount programs: Compare prices at different specialty pharmacies

FAQ: Your Most Common Questions

Q: How long does Cigna prior authorization take in New York? A: Standard PA decisions are made within 72 hours. Expedited requests for urgent situations are processed within 24 hours.

Q: What if Entresto is non-formulary on my plan? A: Your physician can request a formulary exception by documenting that formulary alternatives are ineffective, contraindicated, or previously failed.

Q: Can I request an expedited appeal if denied? A: Yes, expedited appeals are available when your health is at serious risk. Both Cigna internal appeals and New York external reviews offer expedited timelines.

Q: Do I need to use Accredo pharmacy? A: Most Cigna plans require specialty medications like Entresto to be filled through Accredo. Check your specific plan requirements.

Q: What happens if I move from another state where I was already on Entresto? A: Contact Cigna member services immediately to ensure continuity of coverage. You may need a new PA under your New York plan.

Q: Can I appeal if my doctor's office made an error in the PA request? A: Yes, you can file an appeal with corrected information. Consider this a "reconsideration" rather than a true appeal.

When Coverage Gets Complex: Professional Support

Navigating insurance approvals for specialty medications can be overwhelming. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters, identifies the specific denial basis, and drafts point-by-point rebuttals aligned to each plan's own rules, pulling the right clinical evidence and operational details that payers expect.

For complex cases involving multiple denials or unclear coverage policies, having professional support can significantly improve your chances of approval while reducing the administrative burden on your healthcare team.

Sources and Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider regarding treatment decisions and contact your insurance company directly for the most current coverage information. Coverage policies and requirements may change.

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