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

Renewing Entresto (Sacubitril/Valsartan) Approval with Blue Cross Blue Shield in New Jersey: 2025 Requirements & Timeline

Quick Answer: Renewing Your Entresto Coverage

Entresto (sacubitril/valsartan) requires annual prior authorization renewal with Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ). Start your renewal 60-90 days before expiration. You'll need updated heart failure documentation, recent LVEF results, and proof of ongoing benefit. Submit through your cardiologist via Horizon's provider portal or fax. If denied, you can appeal through New Jersey's Independent Health Care Appeals Program (IHCAP) with an 86% success rate when properly documented.

First step today: Check your current PA expiration date by calling Horizon Member Services at 1-800-355-BLUE (2583).

Table of Contents

When to Start Your Renewal

Renewal Triggers & Early Warning Signs

Entresto prior authorizations with Horizon BCBSNJ typically expire after 12 months. Don't wait for the expiration notice—start preparing 60-90 days early.

Key triggers to begin renewal prep:

  • Your pharmacy mentions "prior auth expired" when filling
  • You receive a letter about upcoming formulary changes
  • Your cardiologist schedules your annual heart failure follow-up
  • You're approaching the one-year mark since your last approval
Tip: Set a calendar reminder 90 days before your expected renewal date. Most patients receive their initial approval around the same time each year.

Signs You Should Start Even Earlier

Consider starting your renewal process 120 days early if:

  • Your LVEF has changed significantly (improved or worsened)
  • You've had heart failure hospitalizations
  • Your dosing has been adjusted multiple times
  • You're switching from another heart failure medication to Entresto

Required Documentation Update

Evidence Your Doctor Must Provide

For 2025 renewals, Horizon BCBSNJ requires fresh documentation proving continued medical necessity. Your cardiologist must submit:

Clinical Documentation Checklist:

  • ✅ Updated heart failure diagnosis with ICD-10 codes (I50.x series)
  • ✅ Recent LVEF measurement (within 6-12 months) showing ≤40%
  • ✅ Current NYHA functional class (II-IV) with symptom documentation
  • ✅ Confirmation of ACE inhibitor/ARB intolerance or inadequate response
  • ✅ Absence of contraindications (no angioedema history, stable blood pressure)
  • ✅ Clinical progress notes showing ongoing benefit from Entresto
  • ✅ Current medication list with dosing and titration history

Therapy Response Documentation

What insurers want to see:

  • Functional improvement: Documented reduction in symptoms, improved exercise tolerance, or fewer hospitalizations
  • LVEF monitoring: Serial measurements showing stability or improvement at 3-month and 6-month intervals
  • Medication adherence: Notes confirming patient is taking Entresto as prescribed
  • Titration efforts: Evidence that dose has been optimized per guidelines
From our advocates: We've seen renewals approved faster when the cardiologist includes a brief summary comparing the patient's status before Entresto to their current condition. Even maintaining stability (avoiding decline) can justify continued therapy in heart failure patients.

Renewal Submission Process

How Your Doctor Submits the Renewal

Primary submission methods:

  1. Electronic prior authorization portal (preferred by Horizon)
  2. Fax submission to pharmacy benefits department
  3. Phone request followed by document submission

Required forms and documents:

  • Horizon BCBSNJ prior authorization request form
  • Updated medical necessity letter from cardiologist
  • Recent echocardiogram report or LVEF documentation
  • Clinical notes from last 3-6 months
  • Current medication list
Note: Renewals must be submitted by a cardiologist or include evidence of cardiology consultation. Primary care providers may need to coordinate with a heart specialist.

What Happens During Review

Horizon's pharmacy benefit managers review renewals against their clinical criteria, which generally follow FDA labeling and major heart failure guidelines. The review typically takes:

  • Standard review: 5-7 business days
  • Expedited review: 24-72 hours (if urgent medical need)

Timeline & Decision Windows

Phase Timeline Action Required
Preparation 90 days before expiration Schedule cardiology visit, update testing
Submission 60 days before expiration Doctor submits renewal packet
Review 5-7 business days Horizon reviews documentation
Decision Within 14 days Approval, denial, or request for more info
Appeal (if needed) Within 60 days of denial Submit internal appeal

Expected Decision Windows

Approval scenarios:

  • Straightforward renewal: 5-7 days with complete documentation
  • Additional information requested: 10-14 days total
  • Expedited review: 24-72 hours for urgent cases

If you don't hear back:

  • Call Horizon Member Services after 7 business days
  • Your doctor can request a peer-to-peer review
  • Consider filing an expedited review request if urgent

If Your Coverage Lapses

Bridge Therapy Options

Don't panic if your Entresto coverage lapses. Horizon BCBSNJ offers several safety nets:

Temporary supply options:

  • One-time 31-day emergency fill while renewal is processing
  • Transition supply for new members or formulary changes
  • Appeal period coverage in some cases during internal review

How to request bridge therapy:

  1. Contact your pharmacy and request a "temporary supply fill"
  2. Have your doctor call Horizon to request emergency authorization
  3. Use Horizon's specialty pharmacy network for coordination
  4. Call Member Services at 1-800-355-BLUE (2583) for assistance

Specialty Pharmacy Coordination

Since Entresto is classified as a specialty medication, you must use Horizon's contracted specialty pharmacies for:

  • Emergency fills during coverage gaps
  • Coordination with appeals process
  • Access to patient assistance programs

Annual Plan Changes to Watch

Formulary Updates & Restrictions

Horizon BCBSNJ can modify Entresto's coverage status throughout the year, with major changes typically effective January 1st. Watch for:

Potential changes affecting Entresto:

  • Movement between formulary tiers (affecting copays)
  • New step therapy requirements
  • Quantity limit modifications
  • Prior authorization criteria updates

How you'll be notified:

  • Written notice at least 30 days before changes take effect
  • Updates posted on Horizon's formulary website
  • Pharmacy alerts when filling prescriptions

What to Re-verify Annually

Before each renewal, confirm:

  • Your plan's current formulary status for Entresto
  • Any new prior authorization requirements
  • Changes to preferred specialty pharmacies
  • Updates to appeals processes or contact information

Appeals Process

Internal Appeals with Horizon BCBSNJ

If your Entresto renewal is denied, you have strong appeal rights in New Jersey:

Internal appeal levels:

  1. First-level internal appeal (60 days from denial)
  2. Second-level internal appeal (if required by plan type)
  3. Peer-to-peer review (doctor-to-doctor discussion)

Required for appeals:

  • Copy of denial letter
  • Updated medical necessity documentation
  • Supporting clinical literature
  • Patient impact statement

External Review Through IHCAP

New Jersey's Independent Health Care Appeals Program (IHCAP) provides binding external review after internal appeals are exhausted.

IHCAP process:

  • Filing deadline: 4 months after final internal denial
  • Review timeline: 45 days for standard, 48 hours for expedited
  • Cost: Free to patients
  • Success rate: High reversal rates for well-documented cases
  • Contact: 1-888-393-1062 or through Maximus Federal Services

What makes appeals successful:

  • Complete clinical documentation
  • Clear evidence of medical necessity
  • Reference to heart failure treatment guidelines
  • Documentation of failed alternatives or contraindications

Personal Renewal Tracker

Template for Tracking Your Renewal

Use this checklist to stay organized:

90 Days Before Expiration:

  • Current PA expiration date: ___________
  • Cardiology appointment scheduled: ___________
  • LVEF testing ordered: ___________

60 Days Before Expiration:

  • Updated clinical documentation gathered
  • Medical necessity letter drafted
  • Renewal submitted by doctor
  • Submission confirmation received

During Review:

  • Follow-up call made (if no response in 7 days)
  • Additional information provided (if requested)
  • Decision received: ___________

If Denied:

  • Internal appeal filed within 60 days
  • Appeal documentation submitted
  • IHCAP external review filed (if needed)

Frequently Asked Questions

How long does Entresto prior authorization renewal take with Horizon BCBSNJ? Standard renewals take 5-7 business days with complete documentation. Expedited reviews can be completed in 24-72 hours for urgent medical needs.

What if my LVEF has improved but I still need Entresto? Improved LVEF doesn't automatically disqualify you. Your cardiologist should document that discontinuing Entresto could lead to heart failure progression, following current guidelines that support continued therapy.

Can I appeal if my renewal is denied? Yes. New Jersey provides robust appeal rights including internal appeals with Horizon and binding external review through IHCAP. Success rates are high with proper documentation.

What if I'm switching between Horizon BCBSNJ plans? You may be eligible for transition fills while your new plan processes the prior authorization. Contact Member Services to coordinate coverage during the switch.

Does step therapy apply to Entresto renewals? Generally no, if you're already established on Entresto. New step therapy requirements typically apply only to new starts, not existing patients who are stable on therapy.

Getting Expert Help with Your Renewal

Navigating Entresto renewals can be complex, especially when dealing with changing formularies or prior authorization requirements. Counterforce Health helps patients and providers streamline the renewal process by analyzing denial letters, gathering the right clinical evidence, and drafting targeted appeals that align with each plan's specific criteria. Their platform can identify exactly what documentation Horizon BCBSNJ requires and help ensure your renewal packet meets all requirements the first time.

If you're facing a renewal denial or want to ensure your initial submission is as strong as possible, consider working with specialists who understand the intricacies of each payer's requirements and can help present your case most effectively.

Sources & Further Reading

This guide is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. Prior authorization requirements and appeals processes may change; verify current procedures with your plan before taking action.

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