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

How to Get Entresto (Sacubitril/Valsartan) Covered by Humana in New Jersey: Complete Appeals Guide with Templates

Quick Answer: Getting Entresto Covered by Humana in New Jersey

Entresto requires prior authorization from Humana and is classified as a Tier 3 medication in New Jersey Medicare Advantage plans. Your fastest path to approval: (1) Have your cardiologist submit a prior authorization request with LVEF ≤40% documentation and evidence of ACE inhibitor/ARB intolerance or failure, (2) If denied, file an internal appeal within 65 days with a detailed medical necessity letter, (3) For continued denials, request external review through New Jersey's IHCAP system administered by Maximus Federal Services. Start by calling Humana at 1-800-833-2364 to confirm your plan's specific requirements and formulary placement.

Table of Contents

  1. Understanding Humana's Entresto Coverage in New Jersey
  2. Prior Authorization Requirements
  3. Common Denial Reasons and How to Fix Them
  4. Step-by-Step Appeals Process
  5. Medical Necessity Letter Templates
  6. New Jersey External Review Process
  7. Cost-Saving Options
  8. Frequently Asked Questions

Understanding Humana's Entresto Coverage in New Jersey

Entresto (sacubitril/valsartan) is covered on Humana Medicare Advantage plans with prescription drug coverage in New Jersey, but it comes with important restrictions. The medication is placed in Tier 3 (preferred brand), meaning higher copays than generic alternatives, and requires prior authorization before coverage begins.

Coverage at a Glance

Requirement Details Where to Verify
Prior Authorization Required for all Humana plans Humana Prior Auth Tool
Formulary Tier Tier 3 (preferred brand) Plan's drug list
Step Therapy May require ACE inhibitor/ARB trial first Policy documents
Prescriber Requirement Cardiologist or specialist preferred PA form
LVEF Documentation ≤40% with recent echo required Medical records

The good news? Humana has one of the lowest prior authorization denial rates among Medicare Advantage plans—approximately 3.5% as of 2023. When denials do occur, they're typically due to missing documentation rather than clinical inappropriateness.

Prior Authorization Requirements

Your healthcare provider must demonstrate that Entresto meets specific medical necessity criteria. Here's what Humana requires:

Essential Documentation Checklist

  • Age verification: Patient must be 18 years or older
  • Heart failure diagnosis: Chronic heart failure with NYHA Class II-IV symptoms
  • LVEF documentation: Recent echocardiogram showing LVEF ≤40%
  • Prescriber qualification: Prescribed by or in consultation with a cardiologist
  • Medication history: Documentation of ACE inhibitor or ARB trial, intolerance, or contraindication
  • Safety requirements: No history of angioedema; confirmation ACE inhibitor discontinued ≥36 hours before starting Entresto
Clinician Corner: The most common documentation gap is insufficient detail about prior ACE inhibitor/ARB therapy. Include specific medications tried, dosages, duration, and detailed descriptions of adverse events or treatment failures. Lab values supporting intolerances (like hyperkalemia) strengthen your case significantly.

Common Denial Reasons and How to Fix Them

Denial Reason How to Overturn Required Documentation
"Insufficient LVEF documentation" Submit recent echocardiogram report Echo within 6 months showing LVEF ≤40%
"No evidence of ACE inhibitor trial" Provide detailed medication history Chart notes with specific drugs, doses, outcomes
"Concomitant ACE inhibitor use" Confirm discontinuation timeline Medication reconciliation showing 36+ hour washout
"Not prescribed by specialist" Add cardiology consultation Referral or co-signature from cardiologist
"Quantity limits exceeded" Justify dosing rationale Clinical notes supporting titration plan

Step-by-Step Appeals Process

Level 1: Internal Appeal (Redetermination)

Timeline: File within 65 days of denial notice Response time: 7 days for Medicare Part D

  1. Gather your denial letter and note the specific reason codes
  2. Collect supporting documentation: medical records, lab results, imaging studies
  3. Draft a medical necessity letter (see templates below)
  4. Submit via multiple channels: online portal, fax to 877-486-2621, or mail
  5. Request peer-to-peer review by calling 800-555-CLIN (2546) if needed

Level 2: Independent Review

If your first appeal is denied, you can request an independent review through Medicare's external review process. For Medicare Advantage plans, this involves Maximus Federal Services as the Independent Review Entity (IRE).

Timeline: 30 days for standard review, 72 hours for expedited Cost: Free to you

Medical Necessity Letter Templates

Template for ACE Inhibitor Intolerance

[Date]

Humana Prior Authorization Department
[Address from denial letter]

RE: Appeal for Medical Necessity – Entresto (sacubitril/valsartan)
Member: [Patient Name], ID: [Member ID]
Claim Reference: [Claim Number]

Dear Medical Director,

I am appealing the denial of coverage for Entresto for my patient with chronic heart failure and reduced ejection fraction. This medication is medically necessary based on the following clinical factors:

**Diagnosis**: Chronic heart failure, NYHA Class [II/III/IV]
**LVEF**: [X]% per echocardiogram dated [date]
**Prior Therapy Failures**:
- Lisinopril 20mg daily: discontinued after 3 weeks due to persistent dry cough affecting sleep and quality of life
- Losartan 100mg daily: discontinued after 6 weeks due to hyperkalemia (K+ 5.8 mEq/L) despite dietary counseling

**Clinical Rationale**: According to the 2022 AHA/ACC/HFSA Heart Failure Guidelines, Entresto is recommended as first-line therapy for HFrEF patients who are ACE inhibitor or ARB intolerant. The patient's documented intolerances represent true contraindications to these medication classes.

**Monitoring Plan**: Patient will be monitored with serial BMP, kidney function assessment, and symptom evaluation every 4-6 weeks during titration.

Enclosed documentation includes complete medical records, echocardiogram report, and laboratory results supporting this request.

Sincerely,
[Physician Name, Credentials]
[Contact Information]

New Jersey External Review Process

If your Humana internal appeals are unsuccessful, New Jersey residents have access to the Independent Health Care Appeals Program (IHCAP). However, Medicare Advantage plans follow federal appeal rules, not the state IHCAP process.

For Medicare Advantage Plans (Most Humana Plans)

  • Process: Federal external review through Maximus IRE
  • Timeline: 30 days standard, 72 hours expedited
  • Cost: Free
  • Filing deadline: Must request within appeal timeframe specified in denial letter

For State-Regulated Plans

If you have a state-regulated Humana plan (rare), you can use New Jersey's IHCAP:

  • Administrator: Maximus Federal Services
  • Timeline: 45 days standard, 48 hours urgent
  • Filing window: 4 months from final internal denial
  • Contact: 1-888-393-1062
Note: Most Humana plans in New Jersey are Medicare Advantage and follow federal, not state, appeal procedures. Contact your plan to confirm which process applies.

Cost-Saving Options

Even with coverage, Entresto can be expensive. Here are ways to reduce your costs:

Manufacturer Support

  • Novartis Patient Assistance Program: Income-based free medication for eligible patients
  • Entresto Copay Card: Up to $200/month in copay assistance for commercially insured patients
  • Contact: 1-844-685-3406

Additional Resources

  • Medicare Extra Help: Low-income subsidy program reducing Part D costs
  • State Pharmaceutical Assistance Programs: New Jersey offers PAAD and Senior Gold programs
  • Patient Advocate Foundation: Copay relief program for chronic conditions

At Counterforce Health, we help patients navigate these complex coverage challenges by turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and drafts point-by-point rebuttals aligned with each payer's specific requirements, significantly improving approval rates for specialty medications like Entresto.

Frequently Asked Questions

How long does Humana prior authorization take for Entresto? Standard PA decisions are made within 72 hours for urgent requests, 7 days for routine requests under Medicare Part D rules.

What if Entresto isn't on my Humana formulary? Request a formulary exception by demonstrating medical necessity and providing clinical justification for why formulary alternatives are inappropriate.

Can I get expedited approval for Entresto? Yes, if your doctor certifies that a delay would seriously jeopardize your health. Contact Humana at 1-800-833-2364 to request expedited review.

Does step therapy apply if I've tried ACE inhibitors outside New Jersey? Yes, documented trials from any location count toward step therapy requirements. Ensure your new provider has complete records.

What happens if my appeal is denied? You can request external review through Medicare's independent review process. The decision is binding on Humana if overturned.

How much will Entresto cost with Humana coverage? As a Tier 3 medication, expect higher copays. Exact amounts vary by plan—check your Summary of Benefits or call member services.

From our advocates: We've seen cases where patients were initially denied Entresto coverage due to "insufficient documentation of ACE inhibitor intolerance," only to gain approval after submitting detailed pharmacy records showing specific adverse events and discontinuation dates. The key is providing concrete evidence rather than general statements about "not tolerating" previous medications.

If you need help navigating the appeals process, Counterforce Health specializes in turning insurance denials into successful approvals by identifying the specific denial basis and crafting evidence-backed rebuttals that meet payer requirements.

When to Escalate

If standard appeals fail, consider these escalation options:

  • File a complaint with the New Jersey Department of Banking and Insurance: 1-800-446-7467
  • Contact Medicare at 1-800-MEDICARE for Medicare Advantage issues
  • Consult a patient advocate or healthcare attorney for complex cases

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. Coverage policies and requirements may change—verify current information with official sources before taking action.

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