Effective immediately, Harvard Pilgrim is covering the medication Entresto with prior authorization. In July, the U.S. Food and Drug Administration (FDA) approved Entresto — which is a combination agent containing the novel neprilysin inhibitor sacubitril and the angiotensin II receptor blocker (ARB) valsartan — for use in the treatment of chronic heart failure. Entresto will be covered on the Premium formularies only, at the highest tier (i.e. Tier 3 on the 3-Tier and Tier 4 on the 4-Tier Premium formularies).
Harvard Pilgrim is requiring prior authorization to ensure the safe and appropriate use of Entresto. Harvard Pilgrim's Entresto Clinical Coverage Criteria detail the requirements that must be met in order to obtain prior authorization, including:
- Patient has a diagnosis of chronic heart failure (NYHA class II-IV) with a left ventricular ejection fraction (EF) less than or equal to 40%.
- Entresto is prescribed by (or in consultation with) a cardiologist or specialist in cardiac care.
- Patient is being prescribed Entresto in conjunction with a beta blocker (e.g. metoprolol succinate, carvedilol) and/or Corlanor (ivabradine) for heart failure treatment, or has a contraindication to treatment with a beta blocker.
- Patient has previously tried or has a contraindication (other than angioedema) to treatment with an angiotensin converting enzyme (ACE) inhibitor.
- Patient does not have a history of angioedma related to therapy with an ACE inhibitor or ARB.
If the patient is currently taking an ACE inhibitor or ARB, Entresto will replace that current therapy.
- If the patient has diabetes, he or she is not taking a medication containing aliskiren (e.g. Tekturna or Tekturna HCT).
Approvals will be valid for 12 months. To request prior authorization, please complete the Entresto Medication Request Form and fax it to MedImpact Healthcare Systems at 888-807-6643. For more information, please refer to the Pharmacy section of Harvard Pilgrim's provider website.