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

How to Get Entresto (Sacubitril/Valsartan) Covered by Cigna in Virginia: Forms, Appeals, and Step Therapy Rights

Answer Box: Getting Entresto Covered by Cigna in Virginia

Entresto (sacubitril/valsartan) requires prior authorization from Cigna, with step therapy requiring documented ACE inhibitor or ARB trial failure. Submit your PA request via CoverMyMeds or fax to 1-866-873-8279 with heart failure diagnosis, LVEF results, and medication history. If denied, file internal appeals within 180 days, then pursue Virginia's external review through the State Corporation Commission Bureau of Insurance using Form 216-A within 120 days. Virginia's independent review process has helped many patients overturn wrongful denials for specialty medications.

Table of Contents

  1. Start Here: Verify Your Plan and Coverage
  2. Required Forms and Documentation
  3. Submission Portals and Electronic Options
  4. Fax and Mail Submission Details
  5. Specialty Pharmacy Requirements
  6. Support Lines and Contact Information
  7. Virginia Appeals and External Review Rights
  8. Common Denial Reasons and Solutions
  9. Costs and Financial Assistance
  10. FAQ: Your Questions Answered

Start Here: Verify Your Plan and Coverage

Before requesting prior authorization for Entresto, confirm your specific Cigna plan details by calling the member services number on your insurance card or logging into myCigna.com.

Key Information to Gather:

  • Your formulary tier for Entresto (typically Tier 3-4 specialty)
  • Whether you must use Accredo specialty pharmacy
  • Your copay or coinsurance amount
  • Current step therapy requirements
  • Any quantity limits in place
Note: Cigna manages most specialty drugs through Express Scripts/Accredo, so expect specialty pharmacy requirements for Entresto fulfillment.

Required Forms and Documentation

Prior Authorization Requirements

Your prescribing physician must submit a complete prior authorization request including:

Clinical Documentation Checklist:

  • Heart failure diagnosis with ICD-10 code (typically I50.22 for chronic systolic heart failure)
  • Current left ventricular ejection fraction (LVEF) measurement showing <40%
  • NYHA functional class and symptom description
  • Complete medication history documenting ACE inhibitor or ARB trial
  • Reason for discontinuation (ineffectiveness, intolerance, or contraindication)
  • Medical necessity statement explaining need for Entresto

Administrative Information:

  • Patient's Cigna insurance ID and group number
  • Prescriber NPI and contact information
  • Correct NDC code for Entresto tablets
  • Requested quantity and days supply

Step Therapy Documentation

Cigna requires documentation of prior therapy attempts before approving Entresto. Your physician must provide:

  1. ACE Inhibitor Trial: Name, dose, duration, and specific reason for discontinuation
  2. Alternative Documentation: If ACE inhibitors are contraindicated, ARB trial details instead
  3. Clinical Rationale: Why Entresto is medically necessary based on current heart failure guidelines

Submission Portals and Electronic Options

Electronic Prior Authorization (Preferred Method)

CoverMyMeds Platform: Most efficient option for PA requests

  • Integrated with most EHR systems
  • Real-time status updates
  • Automated follow-up reminders

SureScripts: Alternative electronic submission through your provider's EHR system

Cigna Provider Portal

Healthcare providers can also submit requests through the Cigna for Health Care Professionals portal, though electronic platforms typically process faster.

Tip: Electronic submissions generally receive faster processing times than fax submissions and provide real-time status tracking.

Fax and Mail Submission Details

Fax Submission

Primary Fax Number: 1-866-873-8279 (for pharmacy benefit cases)

Cover Sheet Requirements:

  • Patient's full name and Cigna ID number
  • Prescriber's name and NPI
  • "ENTRESTO PRIOR AUTHORIZATION REQUEST" in subject line
  • Total number of pages being faxed

Mail Submission (If Required)

For any appeals or additional documentation: Cigna Healthcare
Attn: Prior Authorization
PO Box 188011
Chattanooga, TN 37422

Important: Always confirm current fax numbers and addresses, as these can change. Call Cigna member services if you're unsure.

Specialty Pharmacy Requirements

Accredo Enrollment Process

Once Cigna approves your Entresto prescription, you'll likely need to use Accredo specialty pharmacy:

  1. Automatic Enrollment: Cigna may automatically transfer approved prescriptions to Accredo
  2. Patient Portal Setup: Create an account at Accredo.com for order tracking
  3. Delivery Coordination: Accredo will contact you to arrange home delivery
  4. Refill Management: Set up automatic refills through the patient portal or phone

Financial Assistance Through Accredo

Accredo offers copay assistance programs that may help reduce your out-of-pocket costs for Entresto.

Support Lines and Contact Information

Cigna Member Services

Phone: 1-800-244-6224 (24/7)
TTY: Dial 711 for hearing assistance

Provider Relations

Use the provider services number on the back of your Cigna member ID card for the most direct routing to your plan's provider support team.

What to Ask When Calling:

  • Current prior authorization status
  • Required documentation still needed
  • Expected decision timeline
  • Appeal rights if denied
  • Specialty pharmacy requirements

Virginia Appeals and External Review Rights

Internal Appeals Process

If Cigna denies your Entresto request, you have 180 days to file an internal appeal:

  1. First Level: Submit appeal in writing with additional clinical documentation
  2. Second Level: If first appeal is denied, request second-level review
  3. Expedited Appeals: Available for urgent medical situations (24-48 hour decisions)

Virginia External Review Process

After exhausting internal appeals, Virginia residents can request an independent external review through the State Corporation Commission Bureau of Insurance.

Key Steps:

  1. File Form 216-A within 120 days of final internal denial
  2. Submit Required Documents: Denial letters, medical records release, insurance information
  3. Independent Review: Board-certified specialists review your case
  4. Binding Decision: IRO determination is final and binding on Cigna

Virginia External Review Contacts:

  • Mail: State Corporation Commission, Bureau of Insurance – External Review, P.O. Box 1157, Richmond, VA 23218
  • Fax: (804) 371-9915
  • Email: [email protected]
  • Phone: 1-877-310-6560
Virginia Advantage: The state's external review process is free and has helped many patients access necessary specialty medications when insurance companies initially denied coverage.

Common Denial Reasons and Solutions

Denial Reason Solution Strategy
Insufficient heart failure documentation Provide complete echocardiogram results showing LVEF <40%, NYHA class, and current symptoms
No ACE inhibitor trial documented Submit detailed medication history with specific drug names, doses, duration, and discontinuation reasons
Concomitant ACE inhibitor use Confirm ACE inhibitor discontinuation and provide washout period documentation
Quantity limits exceeded Request quantity limit exception with clinical justification for higher dosing
Non-formulary status File formulary exception request with medical necessity documentation

Costs and Financial Assistance

Manufacturer Support Programs

Entresto Copay Card: Novartis offers copay assistance that may reduce out-of-pocket costs to as low as $10 per month for eligible patients. Visit Entresto.com/financial-support for details and eligibility requirements.

Additional Resources

  • Patient Access Network (PAN) Foundation
  • HealthWell Foundation
  • Virginia Medicaid (if eligible)
From Our Advocates: "We've seen patients successfully combine manufacturer copay cards with specialty pharmacy assistance programs to make Entresto affordable. The key is applying for all available programs simultaneously, as eligibility can change based on your specific insurance terms."

FAQ: Your Questions Answered

How long does Cigna take to decide on Entresto prior authorization?
Standard requests: 72 hours. Urgent requests: 24 hours. Electronic submissions typically process faster than fax submissions.

What if Entresto isn't on my Cigna formulary?
You can request a formulary exception by having your physician document medical necessity and failure of formulary alternatives.

Can I get an expedited appeal in Virginia?
Yes, both Cigna and Virginia's external review process offer expedited reviews for urgent medical situations requiring physician certification.

Does step therapy apply if I tried ACE inhibitors outside Virginia?
Yes, documented trials from any location count toward step therapy requirements, provided you have proper medical records.

What happens if Virginia's external review overturns my denial?
Cigna must authorize coverage within 24 hours for expedited cases, or 1-3 business days for standard cases.

Can I use retail pharmacies instead of Accredo for Entresto?
This depends on your specific Cigna plan. Some allow retail pharmacy fills, while others mandate specialty pharmacy use. Check with member services.

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating targeted, evidence-backed documentation that addresses specific payer requirements. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with each insurer's own coverage rules.

Sources and Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and requirements may vary by plan and can change. Always verify current requirements with your insurance company and consult your healthcare provider for medical decisions. For personalized assistance with Virginia insurance issues, contact the State Corporation Commission Bureau of Insurance at 1-877-310-6560.

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