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

How to Get Entresto (Sacubitril/Valsartan) Covered by UnitedHealthcare in Texas: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Entresto Covered by UnitedHealthcare in Texas

UnitedHealthcare requires prior authorization for Entresto (sacubitril/valsartan) with specific heart failure criteria and ACE inhibitor/ARB trial documentation. Your fastest path to approval:

  1. Gather required documents: Recent echocardiogram showing LVEF ≤40%, heart failure diagnosis with ICD-10 code, and documentation of ACE inhibitor/ARB trial or contraindication
  2. Submit UnitedHealthcare's PA form via provider portal with cardiology consultation notes
  3. If denied, file internal appeal within 180 days using medical necessity letter template

Start today: Contact your cardiologist's office to request the prior authorization and ensure all clinical documentation is complete.

Table of Contents

  1. UnitedHealthcare Prior Authorization Requirements
  2. Step-by-Step: Fastest Path to Approval
  3. Common Denial Reasons & How to Fix Them
  4. Medical Necessity Letter Template
  5. Appeals Process in Texas
  6. External Review Through Texas IRO
  7. Costs and Patient Assistance
  8. FAQ

UnitedHealthcare Prior Authorization Requirements

UnitedHealthcare and OptumRx require prior authorization for Entresto with specific clinical criteria that must be documented before approval.

Coverage at a Glance

Requirement What It Means Documentation Needed Source
Heart Failure Diagnosis Chronic heart failure with LVEF ≤40% (HFrEF) ICD-10 code, recent echo UHC PA Form
Cardiology Consultation Prescribed by or with cardiologist Provider credentials, consultation notes UHC PA Form
Prior ACE/ARB Trial Must discontinue before starting Entresto 36-hour washout documentation UHC Coverage Criteria
NYHA Class Class II, III, or IV symptoms Clinical assessment notes UHC PA Form
No Contraindications No angioedema history, severe hypotension Medical history review FDA Label

Step-by-Step: Fastest Path to Approval

1. Confirm Your Diagnosis Meets Criteria

Who: Your cardiologist
What: Document chronic heart failure with LVEF ≤40% and NYHA Class II-IV symptoms
Timeline: Same day as consultation
Submit: Include recent echocardiogram (within 12 months)

2. Document Prior ACE Inhibitor or ARB Use

Who: Prescribing physician
What: Show previous trial of ACE inhibitor or ARB, or document contraindication/intolerance
Timeline: Include in PA submission
Key: If switching from ACE inhibitor, document 36-hour washout period

3. Complete UnitedHealthcare's PA Form

Who: Provider's office
What: Submit UnitedHealthcare Entresto PA form
How: Via UnitedHealthcare provider portal or fax
Timeline: Decision within 2-5 business days for standard requests

4. Include Medical Necessity Letter

Who: Prescribing cardiologist
What: Detailed clinical justification addressing each coverage criterion
Attach: Clinical notes, labs, imaging, medication history

5. Request Peer-to-Peer if Needed

Who: Prescribing physician
What: Call UnitedHealthcare at 866-889-8054, option 3 within 2 business days of denial
Prepare: Clinical rationale, alternative therapy failures, guideline references

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Insufficient heart failure documentation Submit complete echo report and ICD-10 codes Recent LVEF measurement, cardiology consultation notes
No ACE inhibitor trial documented Provide medication history or contraindication Pharmacy records, allergy documentation, adverse event notes
Missing cardiology consultation Get cardiologist involvement Consultation notes or co-signature from board-certified cardiologist
Concurrent ACE inhibitor use Document washout period Medication stop dates, 36-hour gap confirmation
NYHA class not documented Add functional assessment Symptom severity notes, exercise tolerance, daily activity limitations
From Our Advocates: "We've seen the highest success rates when providers submit a complete package upfront—echo results, medication history with specific stop dates, and a detailed letter explaining why Entresto is the appropriate next step. This approach often prevents the need for appeals altogether."

Medical Necessity Letter Template

Essential Elements to Include

Your medical necessity letter should address each UnitedHealthcare criterion systematically:

Patient Information Section:

  • Full name, date of birth, UnitedHealthcare member ID
  • Primary diagnosis: Chronic heart failure (ICD-10: I50.x)
  • Date of diagnosis and current NYHA functional class

Clinical Justification:

[Patient Name] has chronic heart failure with reduced ejection fraction (LVEF [X]% on [date] echocardiogram). Current symptoms include [describe NYHA Class II-IV symptoms: shortness of breath, fatigue, activity limitations].

Previous heart failure management included [ACE inhibitor/ARB name] which was discontinued on [date] due to [specific reason: intolerance/side effects/contraindication]. A 36-hour washout period was observed before initiating Entresto.

Based on current ACC/AHA heart failure guidelines and FDA-approved indication, Entresto is medically necessary to reduce cardiovascular death and heart failure hospitalization risk in this patient with symptomatic chronic HFrEF.

Supporting Evidence:

  • Attach: Recent echocardiogram, cardiology consultation notes, medication history
  • Reference: FDA prescribing information and current heart failure guidelines

Appeals Process in Texas

If your prior authorization is denied, Texas law provides strong appeal rights with specific timelines and procedures.

Internal Appeal Process

Timeline: File within 180 days of denial notice
Decision: UnitedHealthcare must respond within 30 days (pre-service) or 60 days (post-service)
How to File: Via UnitedHealthcare appeals portal or mail/fax as specified in denial letter

Required Documents:

  • Copy of denial letter
  • Medical necessity letter addressing denial reasons
  • All supporting clinical documentation
  • Provider attestation of medical necessity

Expedited Appeals

When Available: Life-threatening conditions or situations where delay would jeopardize health
Timeline: Decision within 72 hours
How: Mark "URGENT" on appeal submission and provide clinical justification for expedited review

External Review Through Texas IRO

If UnitedHealthcare denies your internal appeal, Texas provides independent external review through the Texas Department of Insurance.

Texas IRO Process

Eligibility: Denials based on medical necessity, appropriateness, or experimental/investigational status
Timeline: Request within 45 calendar days of final internal appeal denial
Form: Complete LHL009 form (verify with TDI website)
Cost: No charge to patient; UnitedHealthcare pays IRO fees

IRO Decision Timeframes

Case Type Decision Timeline
Life-threatening conditions Within 8 days (often 3 days)
Pre-authorization requests Within 20 days
Retrospective reviews Within 30 days

IRO Decision: Binding on UnitedHealthcare; if overturned, coverage must be provided

Help Available: Contact Texas Department of Insurance Consumer Help Line at 1-800-252-3439 for guidance on the IRO process.

Costs and Patient Assistance

Entresto Pricing and Support

Typical Cost: Several hundred dollars monthly for brand-name Entresto
Generic Status: Generic versions exist but market availability varies due to ongoing litigation

Patient Assistance Options

Novartis Patient Assistance Program: Income-based support for eligible patients
Copay Cards: May reduce out-of-pocket costs for commercially insured patients
Information: Visit Novartis patient support (verify current programs)

When fighting coverage denials, Counterforce Health helps patients, clinicians, and pharmacies turn insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with payer requirements, potentially saving weeks in the appeals process.

FAQ

How long does UnitedHealthcare prior authorization take in Texas?
Standard PA decisions: 2-5 business days. Expedited requests (urgent medical need): within 72 hours. Appeals: 30-60 days for internal review.

What if Entresto is not on my UnitedHealthcare formulary?
Non-formulary drugs may still be covered through medical exception process. Submit PA with strong clinical justification and evidence that formulary alternatives are inappropriate.

Can I request an expedited appeal?
Yes, if delay would jeopardize your health or for life-threatening conditions. Mark "URGENT" and provide clinical documentation supporting expedited review need.

Does step therapy apply if I tried ACE inhibitors outside Texas?
Yes, medication history from any location counts. Provide pharmacy records or physician documentation of previous trials and outcomes.

What happens if the Texas IRO denies my external appeal?
IRO decisions are final for state-regulated plans. For ERISA plans, federal appeal options may be available. Consult with healthcare advocacy services for complex cases.

How can I track my appeal status?
Use UnitedHealthcare's provider or member portal for real-time status updates. Keep all reference numbers and document all communications.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions vary by individual plan and clinical circumstances. Always consult with your healthcare provider and insurance plan for specific guidance. For additional help with Texas insurance appeals, contact the Texas Department of Insurance at 1-800-252-3439.

Organizations like Counterforce Health provide specialized support for navigating complex prior authorization and appeals processes, helping ensure that evidence-backed appeals meet specific payer requirements and improve approval odds.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.