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

How to Get Entresto (Sacubitril/Valsartan) Covered by Humana in Ohio: ICD-10 Codes, Prior Authorization, and Appeals Guide

Answer Box: Getting Entresto (Sacubitril/Valsartan) Covered by Humana in Ohio

Entresto requires prior authorization from Humana in Ohio. Submit requests through CoverMyMeds or fax to 888-447-3430. Use ICD-10 code I50.22 (chronic systolic heart failure) with documented LVEF <40-50%. Include evidence of ACE inhibitor/ARB intolerance or failure. If denied, you have 65 days to appeal internally, then can request external review through the Ohio Department of Insurance within 60 days.

First step today: Gather your echocardiogram results showing reduced ejection fraction and documentation of previous heart failure medications tried.

Table of Contents

Coding Basics: Medical vs. Pharmacy Benefit Paths

Entresto (sacubitril/valsartan) is an oral medication that follows the pharmacy benefit pathway under most Humana plans in Ohio. This means it's billed using NDC codes rather than HCPCS J-codes, which are reserved for injectable medications.

Key Coverage Details:

  • Formulary tier: Tier 3 (non-preferred brand) on most Humana Medicare Advantage Part D plans
  • Prior authorization required: Yes, for most Humana Ohio plans
  • Quantity limits: Typically 60 tablets per 30 days (standard BID dosing)
  • Step therapy: May require trial of ACE inhibitors or ARBs first
Note: Self-funded employer plans may have different requirements than state-regulated plans. Always verify with the specific plan.

ICD-10 Mapping for Heart Failure

Proper ICD-10 coding is critical for Entresto approval. The diagnosis must clearly support the medical necessity for an ARNI (angiotensin receptor-neprilysin inhibitor).

Primary Codes for Entresto Coverage

ICD-10 Code Description LVEF Range Documentation Required
I50.22 Chronic systolic heart failure <40-50% Most recent LVEF percentage, chronic status
I50.23 Acute on chronic systolic heart failure <40-50% Both chronic HF and acute exacerbation
I50.32 Chronic diastolic heart failure >50% May be covered for specific indications
I50.9 Heart failure, unspecified N/A Avoid - lacks specificity for approval

Documentation Requirements

For successful prior authorization, clinical notes must include:

  1. Specific LVEF value (e.g., "LVEF 35% on echo dated 10/15/2024")
  2. Type of heart failure explicitly stated (systolic, diastolic, or combined)
  3. Chronicity documented (chronic vs. acute vs. acute-on-chronic)
  4. Previous therapy trials with ACE inhibitors or ARBs
  5. Reason for switching (intolerance, contraindication, or inadequate response)
Tip: Never use I50.9 (unspecified heart failure) if you have more specific information. This code doesn't map to risk adjustment categories and weakens prior authorization requests.

Product Coding: NDC Numbers and Billing

NDC Codes by Strength

Entresto comes in three strengths, each with specific NDC codes:

Strength NDC Code Typical Monthly Supply
24/26 mg 55513-301-30 60 tablets
49/51 mg 55513-302-30 60 tablets
97/103 mg 55513-303-30 60 tablets

Billing Format

  • NDC format: Use 11-digit HIPAA format with zero-padding
  • Quantity: 60 tablets for 30-day supply (BID dosing)
  • Days supply: 30 days
  • HCPCS codes: Not applicable for oral medications like Entresto
Important: Entresto does not have a dedicated J-code since it's not an injectable medication. In rare cases requiring medical benefit billing, providers might use J3490 (unclassified drugs) with prior payer approval.

Clean Prior Authorization Request

Essential Components

A successful Humana prior authorization for Entresto should include:

Clinical Information:

  • Primary diagnosis: I50.22 (chronic systolic heart failure)
  • Current LVEF with date of assessment
  • NYHA functional class
  • Current medications and dosages
  • Previous ACE inhibitor/ARB trials with specific names, doses, and outcomes

Supporting Documentation:

  • Recent echocardiogram or cardiac imaging
  • Office visit notes documenting heart failure management
  • Medication history showing prior therapy attempts
  • Laboratory results (BUN, creatinine, potassium)

Sample Documentation Language

"Patient has chronic systolic heart failure (I50.22) with LVEF 30% on echocardiogram dated 10/15/2024. Previously tried lisinopril 10mg daily for 6 weeks with persistent symptoms and enalapril 5mg BID discontinued due to persistent dry cough. Currently NYHA Class II with stable renal function. Requesting Entresto 49/51mg BID per heart failure guidelines."

Common Coding Pitfalls

Frequent Mistakes to Avoid

  1. Missing LVEF documentation: Always include the most recent ejection fraction percentage
  2. Unspecified codes: Don't use I50.9 when more specific information is available
  3. Incomplete prior therapy history: Document specific medications, doses, duration, and reasons for discontinuation
  4. Wrong NDC codes: Ensure the NDC matches the prescribed strength exactly
  5. Quantity mismatches: Standard dosing is BID (60 tablets per 30 days)

Documentation Red Flags

  • Using "heart failure" without specifying type (systolic vs. diastolic)
  • Missing dates on diagnostic tests
  • Vague statements like "patient failed ACE inhibitor" without specifics
  • Concurrent ACE inhibitor prescriptions (contraindicated with Entresto)

Verification with Humana Resources

Before Submitting

  1. Check formulary status: Use Humana's drug list tool to confirm current tier placement
  2. Verify PA requirements: Access the Humana prior authorization search tool
  3. Review quantity limits: Confirm monthly supply allowances for the prescribed strength

Submission Methods

  • Online: CoverMyMeds or Humana provider portal
  • Fax: 888-447-3430
  • Phone: 866-461-7273 (TTY: 711), Monday-Friday, 8 a.m.-11 p.m. Eastern

Processing time: Standard prior authorizations typically take 3-5 business days. Expedited reviews available for urgent cases.

Appeals Process in Ohio

Internal Appeals (First Level)

If Humana denies your Entresto request:

  1. Timeline: 65 days from denial notice to file internal appeal
  2. Method: Submit through Humana member portal, by phone, or mail
  3. Documentation: Include additional clinical evidence, peer-reviewed studies supporting Entresto use, and prescriber attestation
  4. Decision timeframe: 30 days for standard appeals, 72 hours for expedited

External Review (Second Level)

For persistent denials, Ohio residents can request external review through the Ohio Department of Insurance:

  1. Timeline: 60 days after internal appeal denial
  2. Cost: Free to patients
  3. Process: Independent medical experts review the case
  4. Decision timeframe: 30 days standard, 72 hours expedited
  5. Binding: Decision is final and binding on Humana
Note: Self-funded employer plans follow federal ERISA rules rather than Ohio state appeals processes.

Pre-Submission Checklist

Before Submitting Your Prior Authorization

  • Correct ICD-10 code (I50.22 for chronic systolic HF)
  • Recent LVEF documented with date
  • Specific prior ACE inhibitor/ARB trials listed
  • Reasons for prior therapy failures documented
  • Correct NDC code for prescribed strength
  • 60-tablet quantity for 30-day supply
  • Current lab values (especially creatinine and potassium)
  • Prescriber contact information complete

Red Flag Check

  • No concurrent ACE inhibitor prescriptions
  • No history of angioedema documented
  • Adequate washout period from ACE inhibitors noted
  • No unspecified heart failure codes used

FAQ

How long does Humana prior authorization take for Entresto in Ohio? Standard prior authorizations take 3-5 business days. Expedited reviews are available and decided within 72 hours for urgent cases.

What if Entresto is non-formulary on my Humana plan? You can request a formulary exception with medical necessity documentation. Your prescriber will need to demonstrate why preferred alternatives aren't appropriate.

Can I get a temporary supply while waiting for approval? Humana may provide a temporary 30-day supply for new members or during the appeals process. Contact member services to request.

Does step therapy apply if I tried ACE inhibitors outside Ohio? Yes, prior therapy trials from other states count toward step therapy requirements. Ensure your new Ohio provider documents this history.

What's the cost difference between Entresto tiers? As a Tier 3 medication, Entresto typically has higher copays than Tier 1-2 drugs. Under Medicare Part D, your total out-of-pocket costs are capped at $2,000 annually starting in 2025.

When should I contact the Ohio Department of Insurance? If Humana denies your internal appeal or you believe they're not following proper procedures, you can file for external review or submit a complaint.

From our advocates: We've seen many Entresto denials overturned when prescribers include specific LVEF values and detailed prior medication histories. The key is painting a complete clinical picture that clearly shows why standard ACE inhibitors or ARBs aren't sufficient. Don't rush the documentation—thoroughness pays off in faster approvals.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters, identifies the specific coverage criteria, and generates evidence-backed appeals tailored to each payer's requirements. For complex medications like Entresto, we help ensure all clinical documentation and coding requirements are met before submission.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice and should not replace consultation with your healthcare provider. Insurance policies and state regulations can change. Always verify current requirements with your specific plan and consult official sources for the most up-to-date information.

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