Medicare covers a variety of generic and brand-name prescription drugs, including Entresto, to treat heart failure.
Entresto is a brand-name prescription medication containing sacubitril and valsartan. Although the
According to the U.S. Office of Health Policy, beneficiaries paid an average of $357 out-of-pocket for Entresto in 2022. This was the overall average for the year, not per month.
Beneficiaries who received a low income subsidy paid an average of $25. Beneficiaries who did not receive a low income subsidy paid an average of $569.
Medicare Part A is hospital insurance. It covers inpatient services at a general hospital, rehabilitation center, or other approved facility. This includes administering Entresto and other necessary medications during an inpatient stay.
If you don’t meet the criteria for premium-free Part A, you’ll pay $278 or $505 each month. Here are the basic costs for an inpatient hospital stay in 2024:
- $1,632 deductible for each benefit period
- $0 coinsurance for days 1 to 60 of treatment after you pay your deductible
- $408 coinsurance per day for days 61 to 90 of treatment
- $816 coinsurance per day for days 91 to 150 of treatment while using your 60 lifetime reserve days
- 100% of the treatment costs for days 151+
Medicare Part C, also known as Medicare Advantage, is an alternative to Original Medicare. It must offer the same hospital and medical insurance as parts A and B.
Many Medicare Advantage plans also include Part D coverage for prescription drugs (MA-PD).
Each plan sets its own cost and coverage amounts. The premiums, deductibles, copayments, and coinsurance amounts you’ll pay will depend on your chosen plan.
Staying in network — which means getting care from a list of approved healthcare professionals and facilities, including pharmacies — generally costs less than going out of network.
Once you reach the plan’s out-of-pocket maximum, it will pay 100% of all Medicare-approved costs for the rest of the calendar year.
If you are not enrolled in an MA-PD plan, you can purchase a stand-alone prescription drug plan (PDP) as an add-on to Original Medicare. Each plan sets its own cost and coverage amounts.
After you pay your plan’s deductible — up to $545 in 2024 — you will either owe copayments or coinsurance fees when you purchase your prescription. The exact amount depends on the drug’s “tier” in your plan’s formulary.
Entresto is usually considered a tier 3 medication, although some insurance plans include it under tier 2. It ultimately depends on whether your plan considers Entresto a preferred or nonpreferred brand-name medication.
Most plans have a coverage gap or “donut hole.” It begins after you and your plan spend a certain amount — $5,030 in 2024 — on prescriptions.
Once you hit the coverage gap, you pay up to 25% of the cost of Entresto and other brand-name drugs covered by your plan. The manufacturer pays 70%, and your plan pays the remaining 5%.
If your out-of-pocket costs in 2024 reach $8,000, catastrophic coverage kicks in. You won’t pay anything for Entresto and other covered prescriptions for the rest of the calendar year.
In 2025, the coverage gap will be eliminated, and out-of-pocket costs will be capped at $2,000.
Medicare Part A and Part C cover Entresto during an inpatient stay. Many Part C plans also include prescription drugs. If you have Original Medicare, you can purchase a separate Part D plan for prescription drug coverage.
You may be eligible for financial assistance for Part D costs through Medicare’s Extra Help program.