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

How to Get Entresto (Sacubitril/Valsartan) Covered by Humana in New York: PA Guide, Appeals Process & Forms

Answer Box: Getting Entresto Covered by Humana in New York

Entresto (sacubitril/valsartan) is covered by Humana Medicare plans in New York as a Tier 3 medication with prior authorization required. To get approved: (1) Your doctor must document heart failure with reduced ejection fraction (LVEF ≤40%), (2) Submit prior authorization through Humana's provider portal with complete clinical records, and (3) If denied, appeal within 65 days using Humana's redetermination process. Standard approval takes 72 hours; expedited decisions available within 24 hours for urgent cases. Start by having your cardiologist gather your most recent echocardiogram results and heart failure treatment history.

Table of Contents

Plan Types & Coverage Implications

Humana operates primarily as a Medicare Advantage and Medicare Part D provider in New York, with some employer-sponsored plans. Your specific plan type affects how Entresto coverage works:

Medicare Advantage Plans: Most Humana Medicare Advantage members in New York have integrated prescription drug coverage (MAPD plans). These plans combine medical and pharmacy benefits, meaning your Entresto coverage follows both Medicare Part B and Part D rules depending on how it's administered.

Medicare Part D Only: If you have Original Medicare plus a standalone Humana Part D plan, Entresto falls under prescription drug coverage with the same prior authorization requirements.

Employer Plans: Some New York employers offer Humana-administered prescription benefits. These may have different formulary tiers and PA requirements—check your specific plan documents.

Note: All Humana plans in New York must follow federal Medicare guidelines for prescription drug appeals, giving you strong consumer protections.

Formulary Status & Tier Placement

Entresto is included on Humana's 2024-2025 formularies as a Tier 3 (nonpreferred brand) medication across all available strengths: 24/26 mg, 49/51 mg, and 97/103 mg tablets. Here's what this means for your coverage:

Coverage Aspect Details Impact
Formulary Status Covered on most Humana plans ✓ No formulary exception needed
Tier Placement Tier 3 (nonpreferred brand) Higher copay than Tier 1-2 drugs
Quantity Limits 60 tablets per 30 days typical Standard supply restrictions apply
Mail Order Available (MO designation) 90-day supplies allowed
Prior Authorization Required for most plans Must get approval before filling

Alternative medications on lower tiers include ACE inhibitors (lisinopril, enalapril) and ARBs (losartan, valsartan), which explains why Humana requires documentation that these haven't worked for you.

Prior Authorization Requirements

All Humana plans require prior authorization for Entresto, with specific clinical documentation needed for approval. The PA process verifies that you meet FDA-approved indications and clinical guidelines.

Required Documentation

Your prescriber must submit:

  1. Heart Failure Diagnosis: Confirmed chronic heart failure with NYHA Class II-IV symptoms
  2. LVEF Documentation: Recent echocardiogram, MUGA, or cardiac MRI showing ejection fraction ≤40%
  3. Treatment History: Documentation of previous ACE inhibitor or ARB use, including:
    • Specific medications tried
    • Duration of treatment
    • Reason for discontinuation (ineffective, side effects, contraindications)
  4. Current Clinical Status: Recent vital signs, lab values (creatinine, potassium), and symptom assessment

Submission Process

Prior authorization requests must be submitted through:

  • Humana Provider Portal: Online submission with electronic attachments
  • Fax: Check your plan documents for current PA fax number
  • Phone: Provider services line for urgent requests

Timeline: Humana has 72 hours to respond to standard PA requests, or 24 hours for expedited requests when delay could jeopardize health.

Specialty Pharmacy Requirements

Entresto must be dispensed through Humana's network pharmacies, with CenterWell Specialty Pharmacy serving as the preferred partner for New York members. This requirement ensures proper handling of specialty medications and coordinated care management.

CenterWell Specialty Pharmacy Process

  1. Prescription Routing: Your doctor should send Entresto prescriptions directly to CenterWell
  2. Patient Setup: CenterWell will contact you to verify insurance, address, and delivery preferences
  3. Ongoing Support: Pharmacists provide medication counseling and coordinate refills
  4. Supply Limits: Specialty medications typically limited to 30-day supplies initially
Tip: Ask your prescriber to include CenterWell's contact information when writing your Entresto prescription to streamline the process.

Step-by-Step: Fastest Path to Approval

Follow these steps to maximize your chances of first-time approval:

  1. Gather Clinical Documentation (Patient/Caregiver)
    • Request copies of your most recent echocardiogram or cardiac imaging
    • Compile a list of all heart failure medications you've tried
    • Note any side effects or reasons previous medications didn't work
  2. Schedule Cardiology Visit (Patient)
    • Ensure your cardiologist has complete treatment history
    • Discuss Entresto as appropriate therapy for your condition
    • Request written documentation of medical necessity
  3. Submit Complete Prior Authorization (Prescriber)
    • Use Humana's online provider portal for fastest processing
    • Include all required clinical documentation
    • Specify if expedited review is needed
  4. Monitor Authorization Status (Patient/Prescriber)
    • Check portal or call Humana within 48 hours
    • Respond quickly to requests for additional information
    • Document all communications
  5. Coordinate Specialty Pharmacy (Patient)
    • Contact CenterWell Specialty Pharmacy once PA is approved
    • Verify insurance coverage and copay amount
    • Schedule delivery or pickup
  6. Track Initial Fill (Patient)
    • Confirm medication arrives as scheduled
    • Report any issues to both CenterWell and your prescriber
    • Set up automatic refill reminders
  7. Plan for Ongoing Coverage (Patient/Prescriber)
    • Prior authorizations typically need annual renewal
    • Schedule follow-up appointments to document continued medical necessity
    • Keep records of treatment response and any side effects

Common Denial Reasons & Solutions

Understanding why Entresto requests get denied helps you submit stronger initial requests and craft effective appeals:

Denial Reason How to Fix Required Documentation
Insufficient LVEF documentation Submit recent cardiac imaging with specific EF value Echo/MUGA report dated within 6 months
No evidence of ACE/ARB trial Document previous guideline-directed therapy Prescription records, clinic notes showing trials
Concurrent ACE inhibitor use Ensure proper washout period documented Medication reconciliation showing discontinuation
Diagnosis not supported Provide comprehensive heart failure documentation ICD-10 codes, NYHA class, symptom assessment
Missing clinical notes Submit complete provider documentation Office visit notes, treatment plans, monitoring labs

Most common fix: Ensure your prescriber's PA request includes the specific LVEF value (not just "reduced" or "abnormal") and dates of previous ACE inhibitor or ARB trials.

Appeals Process in New York

If your initial Entresto request is denied, New York residents have robust appeal rights under both federal Medicare rules and state insurance protections.

Internal Appeals (Redetermination)

Timeline: You have 65 calendar days from the denial date to file an appeal (extended from 60 days as of January 2025).

Who can file: You, your appointed representative, or your prescribing physician.

Process: Submit written appeal through Humana's member portal, by mail, or fax. Include additional medical documentation addressing the denial reasons.

Decision timeframe: Humana must respond within 7 calendar days for standard appeals, or 24 hours for expedited appeals when health is at serious risk.

External Review (New York State)

If Humana upholds the denial, New York residents can request an external review through the New York State Department of Financial Services (DFS):

  • Timeline: 4 months after receiving final internal denial
  • Cost: Maximum $25 fee (waived for financial hardship or Medicaid)
  • Process: Independent medical experts review your case
  • Decision: Binding on Humana if external reviewer approves coverage
New York Advantage: The state's External Appeal program has overturned many specialty drug denials, particularly when strong medical literature supports the treatment.

When navigating insurance denials and appeals, Counterforce Health helps patients, clinicians, and specialty pharmacies turn denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to identify the specific basis for denial, then drafts point-by-point rebuttals using the right medical evidence and clinical documentation.

Cost-Sharing & Financial Assistance

As a Tier 3 medication, Entresto typically has higher cost-sharing than generic alternatives. Your out-of-pocket costs depend on several factors:

Medicare Part D Cost Phases:

  • Deductible phase: You pay full cost until reaching plan deductible
  • Initial coverage: You pay copay/coinsurance (typically 25-50% for Tier 3)
  • Coverage gap: Higher cost-sharing until reaching catastrophic threshold
  • Catastrophic: Minimal copay/coinsurance for remainder of year

Financial Assistance Options:

  • Medicare Extra Help: Low-income subsidy program reducing prescription costs
  • Novartis Patient Assistance: Manufacturer copay cards and patient assistance programs
  • State Programs: New York may offer additional prescription assistance for eligible residents
Tip: Ask your pharmacist to calculate your annual out-of-pocket costs across all cost phases to budget appropriately.

Clinician Corner: Medical Necessity Documentation

Healthcare providers can improve Entresto approval rates by including these key elements in prior authorization requests:

Medical Necessity Letter Checklist

Patient Problem:

  • Specific heart failure diagnosis with ICD-10 codes (I50.x)
  • NYHA functional class and symptom severity
  • Current LVEF with measurement date and method

Previous Treatments:

  • Complete list of guideline-directed medical therapy trials
  • Specific ACE inhibitors or ARBs tried, with doses and duration
  • Documented reasons for discontinuation (ineffectiveness, side effects, contraindications)
  • Current heart failure medication regimen

Clinical Rationale:

  • Reference to ACC/AHA/HFSA heart failure guidelines supporting Entresto use
  • Expected clinical benefits (reduced hospitalizations, mortality improvement)
  • Patient-specific factors making Entresto appropriate choice

Monitoring Plan:

  • Laboratory monitoring schedule (potassium, creatinine)
  • Follow-up visit timeline
  • Specific clinical endpoints to assess treatment response

Key Guideline References

Include citations from authoritative sources:

  • FDA prescribing information for approved indications
  • ACC/AHA/HFSA Heart Failure Guidelines for treatment recommendations
  • Clinical trial data (PARADIGM-HF) supporting efficacy

When to Escalate: New York State Resources

If standard appeals don't resolve your Entresto coverage issue, New York offers additional consumer protections:

New York State Department of Financial Services

  • External appeal process for medical necessity denials
  • Consumer complaint system for insurance violations
  • Online portal for filing appeals and complaints

Community Health Advocates (CHA)

  • Free insurance counseling and appeals assistance
  • Helpline: 888-614-5400
  • Specializes in helping New Yorkers navigate coverage denials

New York State Health Insurance Assistance Program (SHIP)

  • Free Medicare counseling and appeals support
  • Local counselors available throughout New York
  • Expertise in Medicare Part D appeals process

Frequently Asked Questions

How long does Humana prior authorization take for Entresto in New York? Standard PA requests receive decisions within 72 hours. Expedited requests for urgent medical needs are decided within 24 hours.

What if Entresto isn't on my specific Humana formulary? You can request a formulary exception with supporting medical documentation. The process follows similar timelines as prior authorization requests.

Can I get Entresto from any pharmacy with Humana coverage? Entresto must be dispensed through Humana network pharmacies, with CenterWell Specialty Pharmacy as the preferred partner for specialty medication management.

Does step therapy apply if I've already tried ACE inhibitors outside New York? Yes, prior treatment history from any location counts toward meeting step therapy requirements, as long as it's properly documented in your medical records.

What happens if my Humana plan changes Entresto's formulary status? Plans must provide 60 days' notice of formulary changes. You can request an exception or appeal the change through standard processes.

How often do I need to renew Entresto prior authorization? Most prior authorizations require annual renewal. Your prescriber should submit renewal requests 30-60 days before expiration to avoid coverage gaps.

Can I appeal a Humana denial if I'm also enrolled in Medicaid? Yes, dual-eligible beneficiaries can use both Medicare appeal processes and New York Medicaid fair hearing procedures.

What documentation should I keep for potential appeals? Save all denial letters, medical records, prescription receipts, and correspondence with Humana. These documents are essential for successful appeals.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Coverage policies may vary by specific plan and change over time. Always verify current requirements with Humana directly and consult your healthcare provider regarding appropriate treatment decisions. Counterforce Health provides tools and guidance for insurance appeals but does not guarantee coverage outcomes.

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