Entresto PA removal tied to Cigna’s formulary strategy

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.

Why did Cigna make this change?

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.

  1. Entresto®, a prescription medicine used to reduce risk of death and hospitalization in people with certain types of long-lasting (chronic) heart failure. Usually used with other heart failure therapies, in place of an ACE inhibitor or other ARB therapy. Novartis Pharmaceuticals Corporation, East Hanover, New Jersey. November 2017.
  2. Does not include Individual and Family Plan formularies.
  3. Cigna national book of business clinical study 2018.

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