CurrentUnitedHealthcarePolicy N/A

Entresto (sacubitril/valsartan) prior authorization coverage criteria

Form captures clinical and prescriber information to support prior authorization and reauthorization requests for Entresto for beneficiaries with heart failure; affects prescribing providers and pharmacy PA reviewers for UnitedHealthcare members.

Policy Summary

PayerUnitedHealthcare

PolicyEntresto (sacubitril/valsartan) prior authorization coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed prior authorization form including beneficiary and prescriber information, clinical answers confirming NYHA II-IV and EF ≤40%, safety screening, and prescriber signature.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

NYHA II-IVtarget heart failure class referenced

EF <= 40%left ventricular ejection fraction threshold

365 Daysre-authorization/signature period indicated

1-855-258-1593Pharmacy PA Call Center

Coverage Criteria for Entresto (sacubitril/valsartan)

Initial and reauthorization coverage requirements

Covered when ALL of the following are met

Primary diagnosis and function: Beneficiary has chronic heart failure (NYHA class II-IV) with left ventricular ejection fraction ≤ 40%EF <= 40%

Document EF value on form (List ejection fraction)

Safety screening: No history of angioedema related to an ACE inhibitor or ARB; if currently taking an ACE inhibitor or ARB, indicate whether Entresto will replace that therapy; if diabetic, not taking a medication containing aliskiren

Answers captured on form (history of angioedema, current ACE inhibitor/ARB use and replacement intent, diabetes and aliskiren status)

Administrative requirements: Completed beneficiary and prescriber information, drug details, prescriber signature; for reauthorization, documentation attached demonstrating the beneficiary is receiving clinical benefit (e.g., stabilization or improvement)

Policy Summary

PayerUnitedHealthcare

PolicyEntresto (sacubitril/valsartan) prior authorization coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Provider Actions, Submission & Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization requires submission of the completed pharmacy prior authorization form with beneficiary, prescriber, drug, and clinical information confirming chronic heart failure (NYHA class II-IV) with left ventricular ejection fraction (EF) ≤ 40%. Include prescriber NPI and requester contact information.

Include beneficiary demographics (name, ID, DOB, gender).
Include prescriber information: prescribing provider NPI, requester contact name and phone number.
Include drug details: drug name, strength, quantity per 30 days, and requested length of therapy (up to 30/60/90/120/180 days).
Attach completed clinical questions confirming diagnosis, EF value, ACE inhibitor/ARB history and current use, and diabetes/aliskiren status.
For reauthorization, attach documentation of clinical benefit (e.g., symptom stabilization or improvement).

Note

Concurrent Therapy / Replacement

The PA form asks whether Entresto will replace current ACE inhibitor or ARB therapy and whether the beneficiary is currently taking an ACE inhibitor or ARB. Document current concurrent therapy and indicate if Entresto will replace that therapy when applicable.

Answer whether beneficiary is currently taking an ACE inhibitor or ARB (Yes/No).
If taking an ACE inhibitor or ARB, indicate whether Entresto will replace the current therapy (Yes/No).
If replacing an ACE inhibitor, ensure prescriber documents appropriate washout period per clinical guidance (where applicable).

Documentation Required

Required Documentation

Provide legible, complete documentation. The prescriber's signature and date are mandatory on the PA form. Missing required documentation may delay review or result in denial.

Completed beneficiary demographics (last name, first name, beneficiary ID #, DOB, gender).
Prescriber NPI and requester contact information (name, phone, ext).
Drug name, strength, quantity per 30 days, and selected length of therapy.
Completed clinical questions including: confirmation of chronic heart failure (NYHA II-IV), EF value (≤ 40%), history of angioedema with ACE inhibitor/ARB, current ACE inhibitor/ARB use, diabetes status and aliskiren use if diabetic.
For reauthorization, documentation demonstrating clinical benefit from Entresto (stabilization or improvement).
Prescriber signature and date (mandatory).

Denial Risk

Triggers for Denial

Requests may be denied if required information is missing, incomplete, or unsigned. Common triggers for denial are absence of required diagnosis documentation, no prescriber signature, or missing clinical answers on the PA form.

Missing documentation of diagnosis: no confirmation that beneficiary has chronic heart failure (NYHA II-IV) with EF ≤ 40% and no reported EF value.
Absence of prescriber signature or date on the PA form (signature is mandatory).
Incomplete clinical information: unanswered questions about ACE inhibitor/ARB history/use, angioedema history, diabetes/aliskiren status, or lack of reauthorization benefit documentation.
Missing prescriber NPI or requester contact information.

Background

This PA form is used to request coverage for Entresto (sacubitril/valsartan) for beneficiaries with chronic heart failure. It documents key clinical criteria including New York Heart Association functional class II–IV and a left ventricular ejection fraction of ≤ 40%, requires listing the documented EF value, and captures safety screening for prior angioedema with ACE inhibitors/ARBs and concurrent ACE inhibitor/ARB use (with an item asking whether Entresto will replace current therapy). The form also queries diabetes and concurrent aliskiren use and includes administrative elements such as prescriber signature and contact information to support initial authorization and reauthorization requests.

OpenPayer

Entresto (sacubitril/valsartan) prior authorization coverage criteria

Coverage Criteria for Entresto (sacubitril/valsartan)

Key Clinical Thresholds & Coding

Provider Actions, Submission & Documentation Requirements

Background

Definitions