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

Myths vs. Facts: Getting Entresto (sacubitril/valsartan) Covered by Cigna in Ohio

Answer Box: Getting Entresto Covered by Cigna in Ohio

Myth: If your doctor prescribes Entresto, Cigna automatically covers it. Fact: Cigna requires prior authorization and documented failure of generic ACE inhibitors or ARBs first. To get approved in Ohio: 1) Gather your heart failure diagnosis (LVEF <40%), prior medication trials, and clinical notes, 2) Submit PA through your provider with step therapy documentation, 3) If denied, file internal appeal within 180 days, then external review through Ohio Department of Insurance. Start with Cigna's provider portal or call 1-800-882-4462.

Table of Contents

Why These Myths Persist

Patients and even some providers often misunderstand how specialty drug coverage works, especially for medications like Entresto (sacubitril/valsartan). These misconceptions stem from the complex web of formulary policies, step therapy requirements, and varying state regulations that govern insurance approvals.

In Ohio, where Cigna covers thousands of patients through employer plans and marketplace insurance, the approval process for Entresto involves specific documentation requirements that many people don't fully understand. This leads to preventable denials and unnecessary delays in getting life-saving heart failure treatment.

Counterforce Health helps patients and clinicians navigate these complexities by turning insurance denials into targeted, evidence-backed appeals. The platform identifies denial reasons and drafts point-by-point rebuttals aligned to each plan's specific rules, significantly improving approval rates for specialty medications like Entresto.

Top Myths About Entresto Coverage

Myth 1: "My cardiologist prescribed it, so Cigna has to cover it"

Fact: Cigna requires prior authorization for all Entresto prescriptions, regardless of who prescribes it. Even cardiologists must submit clinical documentation proving medical necessity and step therapy compliance.

Myth 2: "Generic heart failure drugs work the same, so I don't need Entresto"

Fact: Entresto combines a neprilysin inhibitor with an ARB, offering unique cardiovascular benefits for heart failure with reduced ejection fraction (HFrEF). However, Cigna's step therapy policy still requires trying generic ACE inhibitors or ARBs first, unless contraindicated.

Myth 3: "If I've tried other heart medications before, I automatically qualify"

Fact: Cigna requires documented failure or intolerance to specific drug classes (ACE inhibitors like lisinopril, or ARBs like losartan) with detailed clinical notes showing dose, duration, and reason for discontinuation.

Myth 4: "Prior authorization takes weeks to process"

Fact: Cigna makes PA decisions within 72 hours of receiving complete documentation. Expedited reviews are available within 24 hours if delay could harm your health.

Myth 5: "If denied once, I can't get it covered"

Fact: Ohio residents have strong appeal rights. You can file internal appeals with Cigna within 180 days, then request external review through the Ohio Department of Insurance if the denial is upheld.

Myth 6: "Specialty drugs are always non-formulary"

Fact: Entresto is typically on Cigna's formulary as a Tier 3 or 4 medication, but requires prior authorization and step therapy compliance. Non-formulary exceptions are possible with strong clinical justification.

Myth 7: "I need to pay full price until approval comes through"

Fact: Novartis offers a copay assistance program providing up to $4,100 annually for commercially insured patients. You can also request expedited review if you're currently hospitalized or at immediate risk.

Myth 8: "Medicare and commercial plans have the same rules"

Fact: Cigna's Medicare Advantage plans may have different formulary tiers and coverage criteria compared to commercial plans. Always verify your specific plan's requirements.

What Actually Influences Approval

Clinical Documentation Requirements

Cigna evaluates Entresto requests based on specific medical criteria:

Requirement Documentation Needed Source
Heart Failure Diagnosis ICD-10 code I50.22 (chronic systolic HF) Clinical notes with provider attestation
LVEF Documentation Echo or MRI showing LVEF <40% with date/facility Recent cardiac imaging report
NYHA Classification Class II-IV symptoms documented Provider assessment
Step Therapy History Failed ACE inhibitor or ARB with dose, duration, reason Medication history with clinical notes

Administrative Factors

  • Correct NDC codes for the prescribed strength
  • Provider NPI (cardiologist preferred but not required)
  • Complete PA forms submitted via Cigna provider portal
  • Timely submission before prescription expires

Plan-Specific Variables

Different Cigna plans in Ohio may have varying:

  • Formulary tiers (affecting copay amounts)
  • Quantity limits (typically 30-90 day supplies)
  • Site of care restrictions (retail vs. specialty pharmacy)

Avoid These Critical Mistakes

1. Incomplete Step Therapy Documentation

Common error: Saying "patient tried lisinopril but it didn't work." Fix: Document specific details: "Patient trial of lisinopril 20mg daily for 8 weeks discontinued due to persistent dry cough, preventing sleep and affecting quality of life."

2. Missing LVEF Values

Common error: General "heart failure" diagnosis without quantitative data. Fix: Include specific LVEF percentage, test date, and imaging facility: "Echocardiogram 1/15/2024 at Ohio State University Medical Center showed LVEF 28%."

3. Wrong Submission Route

Common error: Submitting through medical benefit instead of pharmacy. Fix: Entresto tablets require pharmacy benefit PA. Use correct Cigna pharmacy prior authorization process.

4. Inadequate Medical Necessity Letters

Common error: Generic template letters without patient-specific details. Fix: Include diagnosis, LVEF, symptoms, prior treatments, contraindications, and treatment goals with guideline references.

5. Missing Appeal Deadlines

Common error: Waiting too long after denial to appeal. Fix: Ohio residents have 180 days to file internal appeals with Cigna, then additional time for external review.

Your 3-Step Action Plan

Step 1: Verify Coverage Requirements (Today)

  • Log into myCigna.com or call member services
  • Confirm Entresto's formulary status and PA requirements
  • Download current PA forms for your specific plan

Step 2: Gather Required Documentation (This Week)

Work with your healthcare team to collect:

  • Recent echocardiogram or cardiac MRI results
  • Complete medication history with trial details
  • Clinical notes documenting heart failure symptoms and functional status
  • Provider letter explaining medical necessity

Step 3: Submit and Track (Next Week)

  • Provider submits PA through Cigna portal or fax 1-866-873-8279
  • Track status online or by calling 1-800-882-4462
  • If denied, immediately begin appeal process with Counterforce Health's assistance if needed

Appeals Process in Ohio

Internal Appeals with Cigna

  • Timeline: File within 180 days of denial
  • Decision: 30 days for standard, 72 hours for expedited
  • Required: Original denial letter, additional clinical documentation, provider letter

External Review through Ohio DOI

If Cigna upholds the denial, Ohio residents can request independent review:

Getting Help

  • Ohio Department of Insurance: 1-800-686-1526 for consumer assistance
  • UHCAN Ohio: Nonprofit advocacy for health coverage issues
  • Legal Aid: For complex appeals or ERISA plan issues

FAQ

How long does Cigna prior authorization take for Entresto in Ohio? Standard PA decisions are made within 72 hours of receiving complete documentation. Expedited reviews are available within 24 hours for urgent situations.

What if Entresto is non-formulary on my Cigna plan? You can request a formulary exception by demonstrating that preferred alternatives are ineffective or contraindicated. Include clinical documentation and provider letter explaining medical necessity.

Can I get expedited appeal if I'm currently hospitalized? Yes, Ohio allows expedited external reviews when delay could seriously endanger health. Decisions typically come within 72 hours.

Does step therapy apply if I failed ACE inhibitors with a different insurer? Cigna may accept prior authorization history from other insurers, but you'll need documentation of the previous trials including doses, duration, and failure reasons.

What's the difference between internal and external appeals in Ohio? Internal appeals are reviewed by Cigna's staff, while external reviews use independent medical experts not employed by the insurer. External review decisions are binding on Cigna.

Can I use manufacturer copay assistance while appealing? Novartis offers copay assistance up to $4,100 annually for commercially insured patients. This can help cover costs during the appeal process.

Resources

Official Sources

Patient Assistance

  • Novartis Patient Assistance: 1-844-ENTRESTO (1-844-368-7378)
  • Ohio Department of Insurance Consumer Hotline: 1-800-686-1526
  • UHCAN Ohio: Universal Health Care Action Network for advocacy support

Professional Resources

  • Counterforce Health - Automated appeal assistance platform
  • American College of Cardiology guidelines for heart failure management
  • Heart Failure Society of America treatment recommendations

This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For questions about Ohio's external review process, contact the Ohio Department of Insurance at 1-800-686-1526.

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