Entresto® (sacubitril/valsartan) is used to reduce the risk of cardiovascular death and hospitalizations for patients with chronic heart failure.1
As of November 15, 2018, the prior authorization (PA) requirement for Entresto was removed across all commercial group formularies.2 This affects all commercial group clients with utilization management (UM) in place. Entresto is subject to the plan’s pharmacy benefit terms of coverage at the 2nd tier/ preferred brand (PB) level on most formularies/plans.
To gain insight on the use and clinical value of Entresto, Cigna conducted a real world evidence study using pharmacy and medical claim data for customers receiving coverage for Entresto. The study compared associated expense of hospitalization claims due to recorded heart failure before and after customers began treatment with Entresto.
Study results showed a reduction in hospitalizations during the period after starting on Entresto, and a corresponding net reduction in total medical cost for the client.3 This evidence, in conjunction with an assessment of the PA on Entresto where we determined that the vast majority of use was consistent with the PA criteria, led to the decision to lift the PA requirement.
This change shows that managing medical and pharmacy in a connected benefit is critical to developing a strategy that helps improve health outcomes and lower total medical cost.
For more information about Entresto, Cigna's actions, and of the study that shows how Entresto can reduce the risk and additional medical costs of heart failure-related hospitalizations, click here.
Health benefit plans vary, but in general to be eligible for coverage a drug must be approved by the Food and Drug Administration (FDA), prescribed by a health care professional, purchased from a licensed pharmacy and medically necessary. Some plans require use an in-network pharmacy for prescriptions to be covered. Coverage is subject to any plan deductible, copayment and/or coinsurance requirements. Product availability may vary by location and plan type and is subject to change. All group health insurance policies and health benefit plans contain exclusions and limitations. For costs and complete details of prescription drug coverage, contact a Cigna representative.
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, (CHLIC), Cigna Behavioral Health, Inc., Cigna Health Management, Inc., Accredo Health Group, Inc., Express Scripts, Inc., ESI Mail Pharmacy Service, Inc., Express Scripts Pharmacy, Inc., Tel-Drug, Inc., Tel-Drug of Pennsylvania, L.L.C., Lynnfield Drug, Inc., and HMO or service company subsidiaries of Cigna Health Corporation. Policy forms: OK - HP-APP-1 et al., OR - HP-POL38 02-13, TN - HP-POL43/HC-CER1V1 et al. (CHLIC). The Cigna name, logo, and other Cigna marks are trademarks of Cigna Intellectual Property, Inc. "Express Scripts" is a trademark of Express Scripts Strategic Development, Inc. This newsletter is not intended for residents of New Mexico.
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