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

How to Get Entresto (Sacubitril/Valsartan) Covered by Humana in Texas: Complete Requirements and Appeals Guide

Quick Answer: Getting Entresto Covered by Humana in Texas

Entresto (sacubitril/valsartan) requires prior authorization from Humana and is typically placed on Tier 3 (preferred brand) with specific documentation requirements. Your fastest path to approval: (1) Ensure your cardiologist documents heart failure with LVEF ≤40% and ACE inhibitor/ARB failure or intolerance, (2) Submit the prior authorization through Humana's provider portal with complete clinical documentation, and (3) If denied, file an appeal within 65 days. Texas residents have strong appeal rights including external review through the Texas Department of Insurance if internal appeals fail.

Table of Contents

Who Should Use This Guide

This guide is designed for Texas residents with Humana Medicare Advantage or Part D coverage who need Entresto for heart failure treatment. You'll find this most helpful if:

  • Your doctor has prescribed Entresto but Humana requires prior authorization
  • You've received a denial letter and need to appeal
  • You're switching from an ACE inhibitor or ARB to Entresto
  • Your pharmacy says Entresto isn't covered under your plan

Expected outcome: With proper documentation, most Entresto prior authorizations are approved. Medicare appeals have an approximately 82% overturn rate when complete clinical evidence is provided.

Member & Plan Basics

Coverage Requirements

  • Prior Authorization: Required for all Humana Medicare Advantage and Part D plans
  • Formulary Tier: Tier 3 (preferred brand) - higher copay than generics
  • Quantity Limits: Typically 60 tablets per 30 days for maximum dose (97/103 mg twice daily)
  • Specialty Pharmacy: May require dispensing through Humana's designated specialty pharmacy network

Plan Type Verification

Check your Humana plan type by logging into your member portal or calling the number on your insurance card. Different plan types may have slightly different requirements, but prior authorization is standard across all Humana plans for Entresto.

Clinical Criteria Requirements

Primary Indication

Entresto must be prescribed for chronic heart failure with documented:

  • LVEF ≤40% (heart failure with reduced ejection fraction)
  • NYHA Class II-IV symptoms
  • Age ≥18 years

Step Therapy Requirements

You must have documentation of:

  • ACE inhibitor or ARB trial with specific drug names, doses, and duration
  • Failure or intolerance with clinical details (e.g., persistent symptoms, adverse reactions, contraindications)
  • 36-hour washout period from ACE inhibitors before starting Entresto

Safety Requirements

  • No history of angioedema
  • No concurrent ACE inhibitor use
  • Adequate kidney function and potassium levels

Documentation Packet Checklist

Required Clinical Documentation

  • Echocardiogram report showing LVEF ≤40% (within 6 months)
  • Heart failure diagnosis with ICD-10 code (typically I50.x)
  • NYHA functional class assessment
  • Complete medication history showing ACE inhibitor/ARB trial
  • Reason for ACE inhibitor/ARB discontinuation (failure or intolerance with specifics)

Medical Necessity Letter Components

Your cardiologist's letter should include:

  • Patient demographics and diagnosis
  • Current LVEF and functional status
  • Detailed prior therapy history with outcomes
  • Clinical rationale for Entresto
  • Planned dosing and monitoring
  • Reference to heart failure guidelines supporting use
Clinician Corner: Include specific adverse events when documenting ACE inhibitor/ARB intolerance. For example: "Lisinopril 20 mg daily discontinued after 3 months due to persistent dry cough interfering with sleep" is stronger than simply "ACE inhibitor intolerance."

Supporting Documents

  • Recent lab results (creatinine, potassium, BNP/NT-proBNP)
  • Hospital discharge summaries (if applicable)
  • Cardiology consultation notes
  • Previous denial letters (if resubmitting)

Submission Process

Step-by-Step Submission

  1. Prescriber initiates prior authorization request through Humana's provider portal
  2. Alternative submission methods:
    • Fax: 877-486-2621 (Part D drugs)
    • Phone: 866-488-5995 (providers)
  3. Complete all required fields - incomplete submissions are the #1 cause of delays
  4. Attach all documentation listed in the checklist above
  5. Request expedited review if clinically urgent (72-hour decision timeline)

Timeline Expectations

  • Standard review: 7 calendar days
  • Expedited review: 72 hours (requires clinical justification)
  • Confirmation: You'll receive a reference number - save this for tracking

When navigating complex insurance requirements like these, Counterforce Health helps patients and providers streamline the prior authorization process by analyzing denial patterns and crafting targeted, evidence-backed appeals that speak directly to each payer's specific requirements.

Appeals Playbook for Texas

Internal Appeals (Level 1)

  • Deadline: 65 days from denial notice
  • Decision timeline: 7 days standard, 72 hours expedited
  • How to file: Humana appeals portal or fax with denial letter and supporting documentation

External Review (Texas IRO)

If Humana denies your internal appeal, Texas law provides additional protection:

  • Deadline: 4 months from final internal denial
  • Process: Independent Review Organization through Texas Department of Insurance
  • Timeline: 20 days standard, 5 days urgent
  • Cost: Free to you (insurer pays)

Texas-Specific Rights

  • Strong appeal protections under Texas Insurance Code
  • IRO decision is binding - if approved, Humana must cover
  • Expedited external review available for urgent cases
  • Help available: Call TDI consumer hotline at 1-800-252-3439

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Insufficient heart failure documentation Submit complete echo report and NYHA class LVEF ≤40%, functional assessment
No ACE inhibitor/ARB trial documented Provide detailed medication history Drug names, doses, duration, outcomes
Missing safety documentation Confirm angioedema history and washout Clinical notes, medication reconciliation
Quantity limit exceeded Justify dosing above standard limits Titration schedule, clinical rationale
Non-formulary status Request formulary exception Medical necessity letter, alternatives tried

Cost Savings Options

Manufacturer Support

  • Novartis patient assistance: Novartis Oncology Patient Assistance (verify with source linked)
  • Copay cards: May reduce out-of-pocket costs for eligible patients
  • Income-based programs: Available for qualifying households

Texas-Specific Resources

  • Medicare Extra Help: Low-income subsidy program
  • State pharmaceutical assistance: Contact Texas Health and Human Services for eligibility

For patients facing repeated denials or complex appeals, Counterforce Health specializes in turning insurance denials into successful approvals by identifying the specific denial basis and crafting point-by-point rebuttals aligned with each plan's own rules.

FAQ

How long does Humana prior authorization take in Texas? Standard reviews take 7 calendar days, expedited reviews 72 hours. Submit complete documentation to avoid delays.

What if Entresto is non-formulary on my plan? You can request a formulary exception with a medical necessity letter explaining why alternatives aren't appropriate.

Can I get an expedited appeal in Texas? Yes, if waiting would jeopardize your health. Your doctor must provide clinical justification for urgency.

Does step therapy apply if I tried ACE inhibitors in another state? Yes, prior therapy documentation from any state counts toward step therapy requirements.

What happens if Humana and the Texas IRO both deny coverage? You can pursue federal Medicare appeals if your case meets dollar thresholds, or explore manufacturer assistance programs.

How do I track my prior authorization status? Use your reference number to check status through Humana's member portal or call customer service at the number on your card.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and should not replace professional medical or legal advice. Coverage requirements may vary by specific plan and change over time. Always verify current requirements with your insurer and consult your healthcare provider for medical decisions. For personalized assistance with Texas insurance appeals, contact the Texas Department of Insurance at 1-800-252-3439.

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