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

The Requirements Checklist to Get Entresto (Sacubitril/Valsartan) Covered by Aetna (CVS Health) in Washington

Quick Answer: Getting Entresto Approved

Entresto requires prior authorization from Aetna (CVS Health) for heart failure patients with LVEF ≤40%. To get approved in Washington: 1) Gather recent echocardiogram showing reduced ejection fraction, 2) Document ACE inhibitor or ARB trial failure, 3) Submit via Aetna provider portal. If denied, you have 180 days to appeal internally, then can request external review through Washington's Independent Review Organization. Most approvals take 14 days with complete documentation.

Table of Contents

  1. Who Should Use This Checklist
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding & Documentation Essentials
  5. Step-by-Step Submission Process
  6. Specialty Pharmacy Routing
  7. After Submission: What to Expect
  8. Common Denial Reasons & Fixes
  9. Appeals Process in Washington
  10. Printable Checklist

Who Should Use This Checklist

This guide is for Washington residents with Aetna (CVS Health) coverage who need Entresto (sacubitril/valsartan) for heart failure with reduced ejection fraction. You'll also find this helpful if you're a healthcare provider submitting prior authorization requests or appealing denials.

Expected outcome: With complete documentation following this checklist, most Entresto prior authorizations are approved within 14 days. If initially denied, appeals have an 82% success rate when proper evidence is submitted.

Member & Plan Basics

Active Coverage Verification

Before starting, confirm your Aetna coverage is active and includes prescription benefits:

  • Call the member services number on your insurance card
  • Verify Entresto requires prior authorization (it does for most Aetna plans)
  • Check if you must use CVS Specialty Pharmacy for this medication

Plan Type Considerations

  • Commercial plans: Standard prior authorization process applies
  • Medicare Advantage: May have additional step therapy requirements
  • Medicaid (Apple Health): Different criteria may apply - verify with Washington state Medicaid
Note: Aetna processes prior authorization requests within 14 days for standard requests, or within 72 hours for expedited reviews when health is in jeopardy.

Clinical Criteria Requirements

FDA-Approved Indications

Entresto is approved for:

  • Adults: Chronic heart failure with reduced ejection fraction (HFrEF) to reduce cardiovascular death and heart failure hospitalization
  • Pediatric patients ≥1 year: Symptomatic heart failure with left ventricular systolic dysfunction

Core Requirements for Approval

Requirement What Aetna Needs Documentation Source
Heart Failure Diagnosis ICD-10 code I50.22 (chronic systolic HF) Provider notes, hospital records
Reduced Ejection Fraction LVEF ≤40% within past 6-12 months Echocardiogram report
NYHA Class Class II-IV symptoms documented Cardiology consultation
Prior ACE/ARB Trial Dose, duration, reason for discontinuation Medication history, provider notes
Prescriber Cardiologist or cardiology consultation Provider NPI and specialty

Step Therapy Requirements

Most Aetna plans require documentation that you've tried and failed (or cannot tolerate):

  • ACE inhibitors (like lisinopril, enalapril)
  • OR ARB medications (like valsartan, losartan)

Important: There must be a 36-hour washout period between stopping an ACE inhibitor and starting Entresto to prevent angioedema.

Coding & Documentation Essentials

ICD-10 Codes for Heart Failure

Use the most specific code that matches your diagnosis:

ICD-10 Code Description When to Use
I50.22 Chronic systolic heart failure Most common for Entresto
I50.21 Acute systolic heart failure During acute episodes
I50.23 Acute on chronic systolic heart failure Exacerbations

NDC Numbers for Billing

Entresto comes in three strengths with specific NDC numbers:

  • 24/26 mg: 0078-0658-01
  • 49/51 mg: 0078-0662-01
  • 97/103 mg: 0078-0667-01
Tip: Always verify current NDC numbers with your pharmacy, as packaging may change.

Step-by-Step Submission Process

Step 1: Gather Required Documents (Patient/Clinic)

Timeline: 1-2 days Documents needed:

  • Recent echocardiogram (within 6-12 months)
  • Complete medication history
  • Provider notes documenting heart failure symptoms
  • Lab results (creatinine, potassium)

Step 2: Complete Prior Authorization Form (Provider)

Timeline: 30 minutes How to submit: Aetna provider portal or fax 1-859-425-3379 Required fields:

  • Patient demographics and insurance information
  • Diagnosis code (I50.22)
  • LVEF value and echo date
  • Prior medication trials and outcomes
  • Prescriber NPI and signature

Step 3: Submit Medical Necessity Letter (Provider)

Timeline: 15-30 minutes Include these elements:

  • Patient's heart failure history and current symptoms
  • Quantitative LVEF from recent echo
  • Previous ACE/ARB trials with specific doses and failure reasons
  • Clinical rationale citing 2022 AHA/ACC/HFSA Heart Failure Guidelines
  • Treatment goals and monitoring plan

Step 4: Track Submission (Patient/Provider)

Timeline: Immediate

  • Record confirmation number
  • Set calendar reminder to check status in 7 days
  • Note appeal deadline (180 days from any denial)

Specialty Pharmacy Routing

Many Aetna plans require Entresto to be filled through CVS Specialty Pharmacy.

Enrollment Process

  1. Provider completes: CVS Specialty Enrollment Form
  2. Submit via: ePrescribe, call 1-800-237-2767, or fax 1-800-323-2445
  3. Patient creates account: Visit CVS Specialty online portal

What CVS Specialty Handles

  • Prior authorization submission on provider's behalf
  • Insurance verification and benefit investigation
  • Medication delivery and refill coordination
  • Patient education and adherence support

After Submission: What to Expect

Standard Timeline

  • Initial review: 3-5 business days
  • Final decision: Up to 14 days
  • Expedited review: 72 hours (if health in jeopardy)

Status Check Schedule

  • Day 3: Check for any requests for additional information
  • Day 7: Verify review is progressing
  • Day 14: Final decision should be received

Confirmation Numbers to Record

  • Prior authorization reference number
  • CVS Specialty enrollment confirmation
  • Any peer-to-peer review scheduling
Note: If you don't receive a decision within the required timeframe, the request may be deemed approved. Contact Aetna member services to confirm.

Common Denial Reasons & Fixes

Denial Reason How to Fix Required Documentation
Missing LVEF documentation Submit recent echocardiogram Echo report with numerical LVEF ≤40%
No prior ACE/ARB trial Provide medication history Pharmacy records, provider notes with doses/dates
Non-cardiologist prescriber Add cardiology consultation Consultation note or co-signature
Insufficient heart failure documentation Enhance clinical notes NYHA class, symptoms, hospitalizations
Missing medical necessity Submit detailed letter Treatment goals, guideline citations, monitoring plan

Scripts for Common Fixes

For missing documentation: "I'm calling to provide additional documentation for prior authorization request #[number]. We have the missing echocardiogram report showing LVEF of [value]% dated [date]. How should I submit this?"

For step therapy appeals: "The patient cannot tolerate ACE inhibitors due to [specific reason - cough, angioedema, hyperkalemia]. We have documentation of this adverse reaction and request a step therapy exception."

Appeals Process in Washington

Internal Appeals (Levels 1-2)

Level 1 Appeal

  • Deadline: 180 days from denial
  • Submit to: Aetna Appeals Resolution Team, PO Box 14463, Lexington KY 40512
  • Fax: 1-859-425-3379
  • Include: Original denial letter, additional clinical evidence, appeal letter

Level 2 Appeal

  • Deadline: 60 days from Level 1 denial
  • Process: Same submission methods as Level 1
  • Enhancement: Consider peer-to-peer review with Aetna medical director

External Review in Washington

If internal appeals are unsuccessful, Washington residents can request an Independent Review Organization (IRO) review.

Key Details:

  • Deadline: 180 days from final internal denial
  • Process: Submit request to Washington Office of Insurance Commissioner
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Cost: Free to patients
  • Decision: Binding on Aetna if overturned

Contact Information:

From our advocates: We've seen many Washington patients successfully overturn Entresto denials through external review, especially when the initial denial cited "not medically necessary" despite clear heart failure guidelines supporting the medication. The key is submitting comprehensive clinical documentation that directly addresses the denial reasons.

Printable Checklist

Before You Start

  • Active Aetna coverage verified
  • Insurance card and policy information ready
  • Recent echocardiogram obtained (within 6-12 months)
  • Complete medication history gathered
  • Provider willing to complete prior authorization

Clinical Requirements Met

  • Heart failure diagnosis documented (ICD-10 I50.22)
  • LVEF ≤40% confirmed on recent echo
  • NYHA Class II-IV symptoms documented
  • ACE inhibitor or ARB trial attempted and failed/not tolerated
  • Cardiology consultation obtained or cardiologist prescribing

Documentation Package Complete

  • Prior authorization form completed
  • Medical necessity letter written
  • Echocardiogram report attached
  • Medication history included
  • Lab results provided (creatinine, potassium)
  • Provider signature and NPI included

Submission Completed

  • Submitted via Aetna provider portal or fax
  • Confirmation number recorded
  • CVS Specialty enrollment completed (if required)
  • Calendar reminders set for status checks
  • Appeal deadline noted (180 days)

When Coverage Gets Complicated

Sometimes even the most thorough prior authorization requests face challenges. That's where specialized support can make a difference. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to identify the specific reasons for denial—whether it's prior authorization criteria, step therapy requirements, or "not medically necessary" determinations—then drafts point-by-point rebuttals using the right clinical evidence and payer-specific requirements.

For Entresto appeals, this might include pulling FDA labeling information, relevant cardiology guidelines, and drug compendia to support off-label uses when appropriate. The system also ensures all the operational details payers expect are included, from accurate ICD-10 coding to proper documentation of prior medication trials. By streamlining this process, patients get cleaner submissions that reduce back-and-forth delays and improve approval rates.

FAQ

How long does Aetna prior authorization take for Entresto in Washington? Standard requests take up to 14 days. Expedited requests (when health is in jeopardy) are processed within 72 hours.

What if Entresto is not on my Aetna formulary? You can request a formulary exception by submitting additional documentation showing medical necessity and that preferred alternatives are inappropriate.

Can I request an expedited appeal in Washington? Yes, if your health could be seriously jeopardized by delays. Call the expedited appeal numbers: Medical (1-877-665-6736) or Behavioral Health (1-866-259-4450).

Does step therapy apply if I tried ACE inhibitors outside of Washington? Yes, medication trials from any location count toward step therapy requirements if properly documented.

What if my doctor isn't a cardiologist? Aetna may require a cardiology consultation for Entresto approval. Your primary care doctor can refer you or provide a co-signature from a cardiologist.

How much does Entresto cost with Aetna coverage? Costs vary by plan. Check your formulary tier and copay information. Entresto manufacturer support may help reduce out-of-pocket costs.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider about your specific medical condition and treatment options. Insurance policies and coverage criteria can change; verify current requirements with your plan. For personalized assistance with appeals in Washington, contact the Office of Insurance Commissioner at 1-800-562-6900.

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