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

How to Get Entresto (sacubitril/valsartan) Covered by Humana in Washington: Appeals Guide & Templates

Quick Answer: Getting Entresto Covered by Humana in Washington

Entresto requires prior authorization from Humana and is typically covered as a Tier 3 medication. If denied, you have 65 days to appeal. The fastest path: 1) Have your cardiologist submit a medical necessity letter documenting your heart failure diagnosis with LVEF ≤40% and any ACE inhibitor/ARB intolerance, 2) File a redetermination request through Humana's member portal, 3) If denied again, request external review through Washington's Office of Insurance Commissioner within 60 days.

Table of Contents

Understanding Humana's Entresto Coverage

Entresto (sacubitril/valsartan) is covered by most Humana Medicare Advantage plans as a Tier 3 non-preferred brand medication with prior authorization requirements. Here's what you need to know:

Coverage at a Glance

Requirement Details Where to Find It
Prior Authorization Required for most plans Humana formulary
Formulary Tier Tier 3 (non-preferred brand) Plan-specific formulary document
Step Therapy May require ACE inhibitor/ARB trial first Denial letter or formulary notes
Quantity Limits Typically 60 tablets per 30 days Plan formulary restrictions
Prescriber Requirements Often requires cardiologist Prior authorization criteria
Diagnosis Documentation Heart failure with LVEF ≤40% Medical records requirement

The key to approval is demonstrating medical necessity through proper documentation of your heart failure diagnosis and any contraindications to alternative medications.

Reading Your Denial Letter

Your Humana denial letter contains crucial information for your appeal. Look for:

Denial Reason Codes:

  • Non-formulary: Entresto isn't on your plan's covered drug list
  • Prior authorization required: Missing PA approval before filling
  • Step therapy: Must try cheaper alternatives first
  • Quantity limit exceeded: Requesting more than plan allows
  • Medical necessity: Plan questions if Entresto is appropriate for your condition

Critical Dates:

  • Date of denial (starts your 65-day appeal clock)
  • Appeal deadline (exactly 65 days from denial date)
  • Reference numbers for tracking your case
Tip: If your denial letter is unclear about the specific reason, call Humana member services at the number on your ID card for clarification before proceeding with your appeal.

Common Fixable Issues

Many Entresto denials can be resolved without a formal appeal:

Missing Documentation

  • Problem: No prior authorization submitted
  • Fix: Have your prescriber submit PA request with required clinical information
  • Timeline: 7 days for standard review

Coding Issues

  • Problem: Wrong diagnosis codes or incomplete clinical information
  • Fix: Ensure ICD-10 codes for heart failure (I50.2* series) are included
  • Timeline: Resubmission within 24-48 hours

Prescriber Requirements

  • Problem: Primary care physician prescribed instead of specialist
  • Fix: Transfer prescription to cardiologist or get specialist consultation
  • Timeline: Same day if coordinated between offices

First-Level Appeal: Redetermination

If initial fixes don't work, file a formal appeal. Humana calls this a "redetermination" for Part D drugs.

Step-by-Step Appeal Process

  1. Gather Required Documents (Patient/Family)
    • Original denial letter
    • Insurance ID card
    • Complete medical records showing heart failure diagnosis
    • Documentation of prior medication trials/failures
  2. Request Medical Necessity Letter (Contact Your Clinic)
    • Call your cardiologist's office
    • Request letter specifically for Entresto appeal
    • Provide them with denial reason from Humana
  3. Submit Redetermination Request (Patient or Prescriber)
  4. Track Your Appeal (Patient)
    • Note confirmation number
    • Humana must decide within 7 calendar days
    • Follow up if you don't hear back within timeline

Medical Necessity Letter Requirements

Your prescriber's medical necessity letter should include these elements based on typical insurance requirements for Entresto:

Required Clinical Information

  • Diagnosis: Chronic heart failure with reduced ejection fraction
  • LVEF Documentation: Recent echocardiogram showing LVEF ≤40%
  • NYHA Class: Functional status (Class II-IV symptoms)
  • Prior Medications: Specific ACE inhibitors or ARBs tried, doses, duration
  • Intolerance/Failure: Documented adverse reactions or lack of efficacy
  • Contraindications: Any medical reasons why alternatives can't be used

Sample Medical Necessity Language

"Patient has chronic heart failure with reduced ejection fraction (LVEF 25% per echocardiogram dated [DATE]) and NYHA Class III symptoms despite optimal medical therapy. Previous trials of lisinopril 20mg daily and losartan 100mg daily were discontinued due to [specific adverse reaction/intolerance]. Entresto is medically necessary per AHA/ACC/HFSA heart failure guidelines for patients who cannot tolerate ACE inhibitors or ARBs."

Peer-to-Peer Review Process

If your initial appeal is denied, request a peer-to-peer review where your cardiologist speaks directly with Humana's medical director.

How to Request

  • Your prescriber calls the number provided in the denial letter
  • If no specific number is listed, contact Humana Provider Services
  • Request must typically be made within 7 days of denial

Preparation Checklist for Your Doctor

  • Patient's complete clinical history
  • Specific adverse reactions to ACE inhibitors/ARBs
  • Current heart failure management plan
  • Relevant clinical guidelines supporting Entresto use
  • Alternative medication considerations and why they're inappropriate

External Review in Washington State

If Humana denies your redetermination, you can request an external review through Washington's Independent Review Organization (IRO) process.

Washington External Review Timeline

Step Timeline Action Required
File Request Within 60 days of final denial Submit to Humana or directly to OIC
IRO Assignment 3 business days Humana forwards case to certified IRO
Submit Additional Info 5 business days You can provide extra documentation to IRO
IRO Decision 20 days (standard) or 72 hours (expedited) IRO reviews and makes binding determination

How to File External Review

  1. Submit Request: Contact Washington Office of Insurance Commissioner at 1-800-562-6900
  2. Required Information:
    • Your insurance policy details
    • Complete denial correspondence
    • All medical records related to your case
    • Any new supporting evidence
  3. IRO Assignment: OIC assigns independent medical experts in cardiology
  4. Final Decision: IRO decision is binding on Humana
Note: Washington's external review process is governed by RCW 48.43.535 and provides strong consumer protections.

Appeal Letter Templates

Patient Appeal Letter Template

[Date]

Humana Inc.
[Address from denial letter]

RE: Redetermination Request
Member: [Your name]
ID Number: [Your member ID]
Claim/Reference Number: [From denial letter]

Dear Review Team,

I am formally requesting a redetermination of your denial dated [DATE] for coverage of Entresto (sacubitril/valsartan). 

My cardiologist has prescribed Entresto for my chronic heart failure with reduced ejection fraction (LVEF [%]). I have documented intolerance to ACE inhibitors and ARBs, specifically [list medications and adverse reactions].

Attached please find:
- Medical necessity letter from my cardiologist
- Echocardiogram results showing LVEF
- Documentation of prior medication trials and adverse reactions
- Current treatment plan

I request that you reverse your denial and approve coverage for Entresto as medically necessary for my condition.

Sincerely,
[Your signature and printed name]
[Phone number]

Attachments: [List all included documents]

Tracking Your Appeal

Keep detailed records throughout the appeals process:

Appeal Log Template

  • Date submitted:
  • Method: (portal, fax, mail)
  • Confirmation number:
  • Documents included:
  • Expected decision date:
  • Actual decision date:
  • Outcome:
  • Next steps:

When to Escalate

Contact the Washington Office of Insurance Commissioner if:

  • Humana misses appeal deadlines
  • You're not receiving proper communication
  • You believe the denial violates Washington insurance law
  • You need help navigating the external review process

If Your Appeal Fails

If both internal appeals and external review are unsuccessful, consider these alternatives:

Formulary Exception Request

  • Request coverage for non-formulary medication based on medical necessity
  • Often requires demonstrating failure of all formulary alternatives
  • Submit through same appeals process

Manufacturer Assistance

  • Entresto Enspire program may provide copay assistance
  • Income-based patient assistance programs available
  • Contact Novartis directly for eligibility requirements

Alternative Medications

Work with your cardiologist to identify covered alternatives:

  • ACE inhibitors with premedication for intolerance
  • ARBs with careful monitoring
  • Combination therapy with other heart failure medications

From Our Advocates

We've seen patients successfully overturn Entresto denials by focusing on the specific clinical documentation requirements. One common winning strategy involves getting a detailed letter from a heart failure specialist that clearly explains why ACE inhibitors and ARBs are contraindicated, rather than just stating "patient cannot tolerate." The more specific the clinical reasoning, the stronger the appeal.

Counterforce Health helps patients, clinicians, and specialty pharmacies navigate insurance denials by creating targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals that align with each payer's specific requirements. For complex cases like Entresto appeals, we help identify the exact clinical documentation and evidence citations needed to build the strongest possible case. Visit CounterforceHealth.org to learn how we can help streamline your appeals process.

FAQ

How long does Humana take to decide on an Entresto appeal in Washington? Humana must make a decision within 7 calendar days of receiving your Part D redetermination request. For expedited appeals (when your health is at immediate risk), the decision comes within 72 hours.

What if Entresto isn't on my Humana formulary at all? You can request a formulary exception by demonstrating medical necessity and showing that all formulary alternatives are inappropriate for your condition. This requires the same documentation as a standard appeal.

Can I get an expedited appeal for Entresto? Yes, if your doctor certifies that waiting for a standard appeal timeline could seriously jeopardize your health. Expedited appeals are decided within 72 hours rather than 7 days.

Does Washington's step therapy law affect Entresto coverage? Washington has patient protections for step therapy requirements. If you've already tried and failed ACE inhibitors or ARBs, or if they're medically inappropriate, you can request an override through the appeals process.

What happens if I miss the 65-day appeal deadline? Contact Humana immediately to request an extension based on good cause (such as serious illness or not receiving proper notice). Washington law provides some flexibility for missed deadlines in certain circumstances.

How much does external review cost in Washington? External review through Washington's IRO process is free for consumers. The insurance company pays the IRO fees regardless of the outcome.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on your specific plan terms and clinical situation. Always consult with your healthcare provider and insurance company for guidance specific to your case. For additional help with insurance appeals in Washington, contact the Office of Insurance Commissioner at 1-800-562-6900.

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