Entresto sprinkle (sacubitril/valsartan) — Highmark
symptomatic heart failure with left ventricular systolic dysfunction in pediatric patients
Initial criteria
- age < 18 years
- diagnosis of symptomatic heart failure (ICD-10: I50.9)
- left ventricular systolic dysfunction
- AND one of the following: member weighs < 40 kg OR (member weighs ≥ 40 kg but < 50 kg AND has experienced therapeutic failure or intolerance to Entresto tablets OR is unable to swallow tablets)
Reauthorization criteria
- age < 18 years
- AND one of the following: member weighs < 40 kg OR (member weighs ≥ 40 kg but < 50 kg AND has experienced therapeutic failure or intolerance to Entresto tablets OR is unable to swallow tablets)
- prescriber attests that member has experienced positive clinical response to therapy
Approval duration
12 months