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

Work With Your Doctor to Get Entresto (sacubitril/valsartan) Approved by Cigna in California

Answer Box: Getting Entresto (sacubitril/valsartan) Covered by Cigna in California

Cigna requires prior authorization for Entresto with step therapy—you must try generic sacubitril-valsartan first. Your cardiologist needs to document heart failure with reduced ejection fraction (LVEF ≤40%) and prior ACE inhibitor or ARB failure/intolerance. If denied, California's Independent Medical Review (IMR) through DMHC offers strong appeal rights with ~55% overturn rates for medical necessity disputes.

First step today: Contact your cardiologist's office to request a prior authorization submission including your LVEF results, medication history, and clinical rationale citing heart failure guidelines.

Table of Contents

  1. Set Your Goal: Understanding Approval Requirements
  2. Visit Prep: Organizing Your Medical History
  3. Building Your Evidence Kit
  4. Medical Necessity Letter Structure
  5. Supporting Peer-to-Peer Reviews
  6. After-Visit Documentation
  7. Respectful Persistence and Escalation
  8. California Appeals Process
  9. FAQ

Set Your Goal: Understanding Approval Requirements

Working with your cardiologist to get Entresto covered by Cigna requires understanding exactly what the insurer needs to see. Cigna's coverage policy mandates prior authorization with step therapy—patients must first try generic sacubitril-valsartan before brand-name Entresto approval.

Coverage Requirements at a Glance

Requirement What It Means Documentation Needed
Step Therapy Try generic sacubitril-valsartan first Trial details or intolerance documentation
Heart Failure Diagnosis HFrEF with LVEF ≤40% Echocardiogram results, ICD-10 code I50.22
Prior Therapy Failure ACE inhibitor or ARB trial Drug name, dose, duration, failure reason
Clinical Guidelines Meets PARADIGM-HF criteria NYHA Class II-IV, guideline-directed therapy

Your partnership with your cardiologist centers on gathering this evidence and presenting it in a way that clearly demonstrates medical necessity according to Cigna's own criteria.

Visit Prep: Organizing Your Medical History

Before your appointment, create a comprehensive timeline that helps your cardiologist build the strongest possible case for Entresto coverage.

Symptom Timeline Preparation

  • Current symptoms: Shortness of breath, fatigue, swelling—when they occur and how they limit daily activities
  • Functional impact: NYHA class assessment (can you climb stairs, walk a block, dress yourself without symptoms?)
  • Hospitalizations: Any heart failure-related ER visits or admissions with dates

Treatment History Documentation

Gather records of every heart medication you've tried:

  • ACE inhibitors (lisinopril, enalapril, captopril): doses, duration, why stopped
  • ARBs (losartan, valsartan, candesartan): same details as above
  • Current medications: beta-blockers, diuretics, other heart failure drugs
  • Side effects experienced: persistent cough, low blood pressure, kidney problems, high potassium
Tip: If you've tried medications with previous doctors or in other states, request those records before your visit. Cigna accepts step therapy trials from any provider when properly documented.

Building Your Evidence Kit

Your cardiologist needs specific clinical evidence to support the prior authorization request. Help them gather:

Essential Lab and Imaging Results

  • Most recent echocardiogram showing LVEF ≤40% (within 6-12 months)
  • BNP or NT-proBNP levels if available
  • Recent lab work: kidney function (creatinine, eGFR), potassium levels
  • Blood pressure readings demonstrating stability

Published Guidelines Support

Your cardiologist should reference these in the medical necessity letter:

  • 2022 AHA/ACC/HFSA Heart Failure Guidelines (Class I recommendation for Entresto in HFrEF)
  • Entresto prescribing information (April 2024 update)
  • PARADIGM-HF trial data showing reduced cardiovascular death and hospitalization

Medication History Summary

Create a simple table for your cardiologist:

Medication Dose Duration Reason for Discontinuation
Lisinopril 10mg daily 3 months Persistent dry cough
Losartan 50mg daily 2 months Hypotension (BP 85/55)

Medical Necessity Letter Structure

Your cardiologist's letter to Cigna should follow this proven structure for maximum impact:

Patient Information Section

  • Specific diagnosis: Heart failure with reduced ejection fraction (ICD-10: I50.22)
  • NYHA functional class: Current symptoms and activity limitations
  • LVEF measurement: Most recent result with date and imaging method

Treatment History Documentation

  • Prior ACE inhibitor/ARB trials with specific reasons for discontinuation
  • Current heart failure medications and optimization status
  • Documentation of step therapy completion or medical rationale for exception

Clinical Justification

  • Reference to treatment guidelines supporting Entresto use in HFrEF
  • Absence of contraindications (no angioedema history, stable blood pressure)
  • Expected clinical benefits based on PARADIGM-HF outcomes
From our advocates: We've seen the strongest approvals when cardiologists include specific LVEF percentages, exact medication trial durations, and direct quotes from the 2022 heart failure guidelines. This level of detail demonstrates thorough clinical assessment and adherence to evidence-based care standards.

Supporting Peer-to-Peer Reviews

If Cigna initially denies your prior authorization, your cardiologist can request a peer-to-peer (P2P) review with Cigna's medical director. Here's how to support this process:

Preparation for P2P Discussions

Offer availability windows to your cardiologist's office for scheduling the call, as these reviews often happen within 24-48 hours of the request.

Help prepare talking points:

  • Patient meets PARADIGM-HF criteria: HFrEF with LVEF ≤40%, NYHA Class II-IV symptoms
  • Step therapy completion: Generic sacubitril-valsartan trial details or medical contraindication
  • Guideline adherence: ACC/AHA Class I recommendation for your specific clinical scenario
  • Safety considerations: Stable blood pressure, no ACE inhibitor contraindications

Supporting Documentation

Ensure your cardiologist has immediate access to:

  • Recent echocardiogram report
  • Complete medication trial history
  • Current lab results showing kidney function and electrolytes
  • Documentation of functional limitations

Counterforce Health specializes in helping patients and clinicians navigate these complex peer-to-peer discussions by providing evidence-backed talking points and payer-specific appeal strategies that align with each insurer's own coverage criteria.

After-Visit Documentation

After your appointment, maintain organized records to support ongoing coverage efforts:

What to Save

  • Copy of the prior authorization submission with all supporting documents
  • Confirmation numbers from Cigna for tracking the request
  • Timeline documentation showing when materials were submitted
  • Any correspondence from Cigna regarding the request status

Portal Communication

Use your patient portal to:

  • Message your cardiologist if you receive any Cigna communications
  • Request copies of submitted documents for your records
  • Update the office on any changes in symptoms or insurance status

Submission Tracking

Monitor your request through:

  • Cigna member portal for real-time status updates
  • CoverMyMeds platform if your doctor uses electronic submissions
  • Direct contact with Cigna at 1-800-882-4462 for prior authorization status

Respectful Persistence and Escalation

Maintaining appropriate follow-up helps ensure your case receives proper attention without overwhelming your healthcare team.

Follow-Up Cadence

  • Week 1: Confirm submission and tracking numbers
  • Week 2: Check status if no response from Cigna
  • Week 3: Discuss appeal options if denied

Escalation Strategies

If your initial request is denied:

  1. Request peer-to-peer review immediately
  2. File internal appeal within 180 days
  3. Prepare for external review through California DMHC if needed

Communication Scripts

For calling Cigna: "I'm calling to check the status of prior authorization request #[number] for Entresto submitted by Dr. [name] on [date]. Can you provide an update on the review timeline?"

For messaging your cardiologist: "I received a denial letter from Cigna dated [date]. Would you like me to forward this to your office, and can we discuss next steps for appeal?"

California Appeals Process

California offers robust patient protections through the Department of Managed Health Care (DMHC) Independent Medical Review system.

Internal Appeal First

File with Cigna within 180 days of denial:

  • Submit through: Cigna member portal or written request
  • Include: Original denial letter, additional medical evidence, prescriber support letter
  • Timeline: Cigna has 30 days to respond (expedited: 72 hours for urgent cases)

Independent Medical Review (IMR)

If Cigna upholds the denial, California residents can request external review:

Eligibility: Medical necessity disputes, experimental/investigational denials Timeline: File within 6 months of final internal denial Process: Independent physician experts review your case Success rates: Approximately 55% overturn rate for medical necessity disputes

How to File IMR

  1. Online: Visit healthhelp.ca.gov for application
  2. Phone: Call DMHC Help Center at 888-466-2219
  3. Timeline: Standard review within 45 days; expedited within 72 hours
  4. Cost: No fee to patients; insurers pay review costs
Note: IMR decisions are binding on Cigna—if the independent review overturns the denial, your plan must authorize coverage.

FAQ

How long does Cigna prior authorization take for Entresto in California? Standard review takes up to 72 hours after Cigna receives complete documentation from your prescriber. Expedited review (24 hours) available if delay would cause health harm.

What if Entresto isn't on my Cigna formulary? Request a formulary exception through your cardiologist. Include clinical rationale for why formulary alternatives are inappropriate for your specific case.

Can I appeal if I tried ACE inhibitors outside California? Yes. Cigna accepts step therapy trials from any provider when properly documented with medication records.

Does step therapy apply if I'm already stable on Entresto? Generally no. If you're already taking Entresto with good clinical response, your cardiologist can request continuation of therapy without requiring step-down to alternatives.

What happens if my appeal is denied in California? You can request Independent Medical Review through DMHC. This external review by independent physicians has strong success rates for medically necessary treatments.

How much does Entresto cost with Cigna coverage? Costs vary by plan tier. Entresto is typically Tier 3-4 specialty, requiring Accredo or Express Scripts specialty pharmacy. Check your specific copay through the Cigna member portal.

Sources & Further Reading

Navigating insurance coverage for specialty medications like Entresto requires persistence and proper documentation, but California's strong patient protection laws provide meaningful appeal rights when initial requests are denied. Counterforce Health helps patients and clinicians turn insurance denials into successful appeals by providing targeted, evidence-backed strategies that align with each payer's specific coverage criteria.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider regarding treatment decisions and contact your insurance plan directly for coverage determinations. Appeal rights and processes may vary by specific plan type.

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