Does Medicare Cover Entresto?

Which Part of Medicare Covers Entresto?

Entresto (the brand name for sacubitril and valsartan) is a pill you take at home. Medicare covers self-administered prescription drugs through Part D, not through the hospital benefit (Part A) or the medical benefit (Part B). So if you have only Original Medicare (Parts A and B) and no drug plan, Medicare will not pay anything toward Entresto.

To get any Medicare help with Entresto, you need one of two things: a standalone Part D prescription drug plan (a PDP, which you can add to Original Medicare), or a Medicare Advantage plan that includes drug coverage (called an MA-PD plan). Either way, Entresto must appear on that plan's formulary, the list of drugs the plan agrees to cover.

Medicare Advantage plans almost always bundle drug coverage, so most MA-PD plans can cover Entresto if it is on their formulary. But coverage, tier placement, and cost vary from plan to plan, so always check the specific plan.

• Part A (hospital): does not cover Entresto.
• Part B (doctor/outpatient): does not cover Entresto, because it is a self-administered pill.
• Part D (standalone drug plan): can cover Entresto if it is on the plan's formulary.
• Medicare Advantage with drug coverage (MA-PD): can cover Entresto if it is on the plan's formulary.

What Entresto Treats and Who It Is For

Entresto is FDA-approved to reduce the risk of cardiovascular death and hospitalization in adults with chronic heart failure. The benefit is most evident in patients whose heart pumps below a normal level (a reduced left ventricular ejection fraction). It is also approved for children aged one year and older with certain heart failure, though that use rarely applies to Medicare beneficiaries.

Whether your plan covers Entresto for your situation does not change its FDA approval, but a plan may still ask your doctor to confirm the medical reason before approving coverage.

How Much Does Entresto Cost With Medicare in 2026?

Your out-of-pocket cost for Entresto depends on your plan's deductible, the tier Entresto sits on, and where you are in the year. Two 2026 changes work in your favor: a Medicare-negotiated price for Entresto and a hard yearly cap on what you pay for drugs.

Entresto was selected for the Medicare Drug Price Negotiation Program. Its negotiated Maximum Fair Price takes effect January 1, 2026 and is about $295 for a 30-day supply, a 53% reduction from the drug's 2023 list price. A lower underlying price generally means a lower share for you.

Here is how Part D cost-sharing works in 2026, in order:

• Deductible: You first pay any plan deductible. No 2026 Part D plan can charge more than $615, and some plans charge $0.
• Coinsurance: After the deductible, you pay 25% of the cost of covered drugs, including Entresto, until you reach the out-of-pocket cap.
• Out-of-pocket cap: Once your out-of-pocket drug spending reaches $2,100 in 2026, you pay $0 for covered Part D drugs (including Entresto) for the rest of the calendar year.
• Premium: Your Part D premium is separate from your Entresto copay. The 2026 national base beneficiary premium is $38.99 per month; actual plan premiums vary.

Coverage Rules, Restrictions, and Ways to Pay Less

A plan may place coverage rules (called utilization management) on Entresto. Common rules include prior authorization (your doctor must get the plan's approval first) or step therapy (you may have to try other heart-failure drugs before the plan covers Entresto). These rules and Entresto's tier vary by plan, so review the plan's formulary before you enroll.

If a plan denies Entresto or imposes a restriction, you or your prescriber can request a coverage determination. If that is denied, you can appeal through Medicare's multi-level Part D appeals process.

Several programs can lower or smooth your costs:

• Extra Help (Part D Low-Income Subsidy): If you have limited income and resources, Extra Help lowers premiums, deductibles, and copays. In 2026, people with Extra Help pay no more than $12.65 for each covered brand-name drug. 2026 income limits are generally $23,475 for an individual or $31,725 for a married couple living together; resource (asset) limits are $16,590 individual or $33,100 for a couple (not counting the burial exclusion).
• Medicare Prescription Payment Plan: You can spread your Part D out-of-pocket costs across the year in interest-free monthly payments with no fees, which can help with a high-cost brand drug like Entresto.
• Late enrollment penalty: If you delay Part D when you have no other creditable drug coverage, you may owe a penalty of 1% of $38.99 times the number of full months you went without, added to your premium for as long as you have Part D. This matters if you later need Entresto.
• Higher-income surcharge (IRMAA): If your 2024 income (MAGI) was above $109,000 single or $218,000 joint, you pay a Part D surcharge of $14.50 to $91.00 per month in 2026, on top of your plan premium.
• No generic yet: Entresto is covered as a brand-name drug. Confirm tier and cost on each plan you compare.

How to Find a Plan That Covers Entresto

Because every plan's formulary, tier, deductible, and restrictions differ, the smartest move is to compare plans using Medicare's official Plan Finder at Medicare.gov. Enter Entresto and your dosage, and the tool shows which plans cover it, the estimated yearly cost, and whether prior authorization or step therapy applies.

Review plans during a valid enrollment period, such as the Annual Open Enrollment (October 15 to December 7) or when you first qualify for Medicare. If you already have a plan, recheck each fall, because formularies and prices can change every year.