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

Myths vs. Facts: Getting Entresto (Sacubitril/Valsartan) Covered by Blue Cross Blue Shield in Michigan

Answer Box: Getting Entresto Covered by Blue Cross Blue Shield in Michigan

Myth: Doctor prescriptions guarantee insurance approval. Fact: Blue Cross Blue Shield of Michigan requires prior authorization for Entresto, including documented heart failure with LVEF ≤40%, NYHA class II-IV symptoms, and evidence of ACE inhibitor/ARB trial or intolerance. Submit PA via BCBSM provider portal with echocardiogram, clinical notes, and medication history. Standard approval takes 5-7 business days; expedited reviews available for urgent cases. If denied, appeal within 60 days internally, then request external review through Michigan DIFS within 127 days.

Table of Contents

Why Entresto Coverage Myths Persist

Heart failure patients and their families often believe that a cardiologist's prescription automatically guarantees insurance coverage. This misconception stems from the life-threatening nature of heart failure and the assumption that "medically necessary" means "automatically covered."

The reality is more complex. Entresto (sacubitril/valsartan), manufactured by Novartis, is a breakthrough heart failure medication that costs several hundred dollars monthly. Blue Cross Blue Shield of Michigan, like most insurers, has implemented utilization management protocols to ensure appropriate use and control costs.

Understanding these requirements—rather than hoping they don't apply—is your fastest path to approval.

Common Myths vs. Facts

Myth 1: "If my cardiologist prescribes Entresto, Blue Cross Blue Shield must cover it immediately."

Fact: Blue Cross Blue Shield of Michigan requires prior authorization (PA) for Entresto. According to BCBSM's PA guidelines, coverage requires documented chronic heart failure with reduced ejection fraction (HFrEF), typically LVEF ≤40%, and NYHA class II-IV symptoms despite optimal standard therapy.

Myth 2: "Entresto is automatically covered because it's FDA-approved for heart failure."

Fact: FDA approval doesn't guarantee insurance coverage. BCBSM requires step therapy, meaning you must first try and fail (or show intolerance to) ACE inhibitors or ARBs at maximum tolerated doses. The clinical criteria specifically require documentation of prior therapy trials.

Myth 3: "I can't get Entresto covered if I'm stable on my current heart failure medications."

Fact: If you meet clinical criteria (LVEF ≤40%, appropriate NYHA class, documented ACE/ARB trial), you may still qualify even if currently stable. The key is demonstrating that Entresto offers superior cardiovascular outcomes based on guidelines and your specific clinical situation.

Myth 4: "Appeals never work with Blue Cross Blue Shield."

Fact: Michigan's external review process through DIFS shows reasonable success rates when proper documentation is provided. Appeals often succeed when clinical criteria are clearly met but were inadequately documented in the initial PA request.

Myth 5: "Generic alternatives work just as well, so insurance won't cover brand Entresto."

Fact: While generic sacubitril/valsartan approvals exist, market availability remains limited due to ongoing litigation. Entresto's unique mechanism (neprilysin inhibitor + ARB) differs from standard ACE inhibitors and ARBs, potentially justifying coverage when step therapy requirements are met.

Myth 6: "I need a heart failure specialist to get Entresto approved."

Fact: While cardiologist involvement strengthens your case, any qualified physician can prescribe Entresto and submit PA requests. However, specialist documentation of heart failure severity and treatment history significantly improves approval odds.

What Actually Influences Approval

Clinical Documentation Requirements

Blue Cross Blue Shield of Michigan's approval decisions hinge on specific clinical evidence:

Requirement Documentation Needed Source
Heart Failure Diagnosis ICD-10 codes I50.x, clinical notes confirming NYHA class BCBSM Clinical Criteria
LVEF Documentation Recent echocardiogram, MUGA, or cardiac MRI showing LVEF ≤40% PA Guidelines
Prior Therapy Chart notes documenting ACE inhibitor/ARB trials, doses, duration, outcomes BCBSM Step Therapy Requirements
Safety Screening No history of angioedema, current K+ levels, eGFR >30 mL/min FDA Prescribing Information

Step Therapy Requirements

BCBSM typically requires documented trial of:

  • Beta-blocker (e.g., metoprolol, carvedilol)
  • ACE inhibitor (e.g., lisinopril, enalapril) OR ARB (e.g., valsartan, losartan)
  • Mineralocorticoid receptor antagonist when appropriate

Exceptions apply for:

  • Documented intolerance (cough, hyperkalemia, angioedema)
  • Contraindications (pregnancy, bilateral renal artery stenosis)
  • Clinical deterioration on standard therapy

Avoid These Critical Mistakes

1. Submitting Incomplete Clinical Documentation

Common Error: Sending PA requests without recent echocardiogram results or specific LVEF values.

Solution: Ensure your provider includes:

  • Exact LVEF percentage from imaging within past 12 months
  • NYHA functional class assessment
  • Complete medication history with doses and durations

2. Ignoring Step Therapy Requirements

Common Error: Requesting Entresto without documenting prior ACE inhibitor/ARB trials.

Solution: Even if you haven't tried these medications, discuss with your provider about documented contraindications or reasons why step therapy isn't appropriate for your specific case.

3. Missing the 36-Hour ACE Inhibitor Washout

Common Error: Starting Entresto without proper ACE inhibitor washout period, creating safety concerns.

Solution: Your provider must document the washout period when transitioning from ACE inhibitors to prevent dangerous interactions.

4. Using Wrong Submission Channels

Common Error: Faxing PA requests to outdated numbers or using incorrect forms.

Solution: Submit via BCBSM's provider portal or verify current PA fax numbers directly with BCBSM provider services at 1-888-288-1726.

5. Failing to Appeal Promptly

Common Error: Waiting months after denial to file appeals, missing critical deadlines.

Solution: File internal appeals within 60 days of denial; request external review through Michigan DIFS within 127 days of final internal denial.

Quick Action Plan: Three Steps to Take Today

Step 1: Gather Required Documentation

Call your cardiologist's office and request:

  • Most recent echocardiogram report with LVEF
  • Complete heart failure medication history
  • Current lab results (kidney function, potassium)
  • Documentation of any ACE inhibitor/ARB trials or contraindications

Step 2: Verify Your Plan's Requirements

Contact BCBSM member services at 1-888-288-1726 and ask:

  • "Does my plan require prior authorization for Entresto?"
  • "What are the specific clinical criteria?"
  • "Which forms does my doctor need to submit?"

Step 3: Schedule Provider Discussion

Meet with your prescribing physician to:

  • Review clinical criteria together
  • Discuss step therapy requirements
  • Plan PA submission strategy
  • Set timeline expectations
From Our Advocates: We've seen patients successfully obtain Entresto coverage by working closely with their cardiologist to document a clear clinical narrative—one patient's approval was secured after their doctor detailed how ACE inhibitor therapy caused persistent cough that significantly impacted quality of life, making Entresto medically necessary despite stable heart function.

Michigan-Specific Appeals Process

Internal Appeals with BCBSM

If your initial PA request is denied:

  1. File within 60 days of denial notice
  2. Submit via BCBSM member portal or mail to address on denial letter
  3. Include updated clinical documentation addressing specific denial reasons
  4. Timeline Standard review: 30 days; expedited: 72 hours for urgent cases

External Review Through Michigan DIFS

After internal appeal denial, you have powerful state-level protections:

Timeline: Must file within 127 days of final internal denial Process: Submit request through Michigan DIFS external review Decision Time: 60 days standard; 72 hours for expedited reviews Contact: Michigan DIFS at 877-999-6442

Required Documents:

  • Copy of final denial letter from BCBSM
  • Reason for appeal
  • Supporting clinical documentation
  • Treating provider certification (if applicable)

When to Request Expedited Review

Request expedited appeals when:

  • You're hospitalized for heart failure
  • Your condition is rapidly deteriorating
  • Delay in treatment poses serious health risks

Your physician must provide a letter confirming medical urgency.

Resources and Support

Cost Assistance Programs

  • Novartis Patient Assistance: Entresto copay card may reduce costs to $10/month for eligible patients
  • Michigan Department of Health and Human Services: May provide additional support for qualifying residents

Professional Support

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements by analyzing denial letters and crafting point-by-point rebuttals aligned with payer policies. For complex cases involving multiple denials or unclear clinical criteria, professional advocacy can significantly improve approval odds.

Official Resources

Frequently Asked Questions

Q: How long does BCBSM prior authorization take for Entresto? A: Standard PA reviews take 5-7 business days. Expedited reviews for urgent cases are completed within 24-48 hours.

Q: Can I start Entresto while waiting for PA approval? A: Generally no, unless you're paying out-of-pocket. Starting without approval may result in claim denials and significant costs.

Q: What if Entresto isn't on my formulary? A: Request a formulary exception through your provider, including clinical justification for why formulary alternatives are inappropriate.

Q: Does step therapy apply if I tried ACE inhibitors years ago? A: Recent trials are typically required. Discuss with your provider about documenting why re-trialing isn't clinically appropriate.

Q: Can I appeal if I'm denied due to stable heart function? A: Yes, if you meet LVEF criteria. Appeals should emphasize Entresto's proven mortality and hospitalization benefits even in stable patients.

Working with specialized services like Counterforce Health can help ensure your appeal addresses these nuances effectively, particularly when clinical criteria appear to be met but initial requests were denied due to documentation gaps.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider regarding treatment decisions and insurance coverage options. Coverage policies may vary by specific BCBSM plan and are subject to change.

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