Does Medicare Cover Entresto

Does Medicare Cover Entresto? 

There’s no question that your heart is one of your body’s most vital organs. Without a properly functioning heart, blood can’t circulate and your body will cease to perform. This is why conditions like heart failure need to be addressed at once. During heart failure, the various pressure mechanisms of the heart either do not pump blood adequately or the heart does not fill with blood adequately. When this failure takes place, the rest of the body can’t receive enough clean, oxygenated blood, leading to the failure of the rest of your organs.

How is heart failure treated?

Heart failure treatment depends on the cause of the dysfunction. In cases of congestive heart failure, lifestyle adjustments and cholesterol and blood pressure medications may be needed. When a blocked artery leads to a complete stoppage of blood flow, surgery may be required to treat the blockage or route around it. In other cases where the heart is enlarged and too weak to pump blood properly, prescription medications like Entresto may be able to relieve symptoms.

How does Entresto work?

Entresto (sacubitril/valsartan) works by suppressing the secretion of a specific peptide hormone in the body that affects smooth muscle. The medication also controls blood vessel dilation and constriction to aid in better blood flow through easier circulation. Entresto is available as a tablet that combines both sacubitril and valsartan, and it may be used as a replacement medication for an ACE inhibitor.

Does Medicare cover Entresto?

Medicare covers Entresto under Medicare Part D, the prescription drug coverage benefit. Each plan is different, and each plan has its own formulary, so you will need to consult your plan materials to know your specific coverage limitations. Your plan’s formulary is a list of all covered medications under Medicare Part D’s prescription drug coverage within a specific plan. If Entresto is not covered and no suitable alternative exists, you may need to work with your doctor to file a waiver request for an exception through Medicare.

In cases where Entresto is administered during a hospital stay or while you are admitted to a skilled nursing facility, the medication will likely be covered by Medicare Part A, the inpatient benefit. If Entresto is administered during a clinical visit, it will be covered by Medicare Part B. Keep in mind that Medicare Part D coverage only applies when you purchase a medication at a retail pharmacy for self-administration at home.

Does Medicare Advantage cover Entresto?

Since Medicare Part D usually provides coverage for Entresto, Medicare Advantage plans that include prescription drug coverage may also receive coverage. You may, however, be able to receive additional benefits that address heart failure when you take part in a Medicare Advantage plan. This is because Medicare Advantage plans often offer benefits that exceed those offered by Original Medicare. To learn more, speak with your plan manager or consult your plan materials for details.