Does Medicaid cover Entresto?

In this article:

• Does Medicaid cover Entresto?
• Factors influencing Medicaid coverage for Entresto
• How much does Entresto cost?
• Cost of Entresto with Medicaid
• How to get Entresto with Medicaid
• Ways to get discounts on Entresto without Medicaid

In this article

• Does Medicaid cover Entresto?
• Factors influencing Medicaid coverage for Entresto
• How much does Entresto cost?
• Cost of Entresto with Medicaid
• How to get Entresto with Medicaid
• Ways to get discounts on Entresto without Medicaid

Heart failure is a long-term health condition where the heart struggles to pump blood as well as it should, leading to serious health issues. Entresto helps your heart pump better, reducing the risk of hospital visits and death from heart failure. It combines two medications: sucabitril and valsartan, and it can be expensive if you don’t have insurance coverage.

With Medicaid, each state manages its own program with the federal government. What your state covers may be different from what another state covers. Overall, Medicaid coverage for Entresto will depend on several factors, including where you live, your annual income, and more. 

Does Medicaid cover Entresto?

Medicaid coverage for Entresto varies by state. Some states might cover Entresto, while others might not. Even if it is covered, there may be rules about who can get it. Here are a few examples:

• Texas Medicaid: It may cover Entresto if it’s prescribed for heart failure when other treatments are ineffective.
• California Medicaid (Medi-Cal): This might require getting approval from your insurance, and your healthcare provider may need to provide evidence that other medications were used first.
• New York Medicaid: Coverage may be available but with specific requirements based on medical necessity.

To determine if your state covers Entresto, check with your state’s Medicaid website or call your local Medicaid office. 

Factors influencing Medicaid coverage for Entresto

If Medicaid does cover Entresto in your state, you might need to meet certain conditions. Here are some factors that could influence whether Medicaid will cover Entresto for you:

• Your diagnosis: Medicaid might need a specific diagnosis to cover Entresto.
• Previous treatments you’ve tried: Some states might require you to try other, less expensive medications before they will cover Entresto. This process, called step therapy, involves trying different medications before getting approval for Entresto.
• Prior authorization: Your healthcare provider might need to get authorization from Medicaid before you can start using Entresto. This process involves your healthcare provider sending information about your medical history and why Entresto is necessary for your treatment. It can take some time, so starting the process as soon as possible is essential to getting Entresto.

How much does Entresto cost?

Without insurance or Medicaid, the average retail price of Entresto is $940 for 60, 24–26 mg tablets, which is a one-month supply. But this is an average cost, and several factors can influence what you pay:

• Dosage: If your healthcare provider prescribes a higher dose, it may cost more than lower doses. 
• Pharmacy: Different pharmacies may charge different prices for Entresto. It’s a good idea to check prices at different pharmacies and have your prescription filled at the one that’s most affordable. 
• Location: The price of Entresto can also vary depending on where you live. Some areas have higher or lower prices than others, even if they’re the same pharmacy chain.

Cost of Entresto with Medicaid 

The cost of Entresto with Medicaid depends on your state’s specific Medicaid plan. Medicaid usually helps lower the cost of prescription drugs. However, you might need to plan for out-of-pocket expenses, such as:

• Copays: Some states might ask for a small fee for each prescription. This copayment amount is usually low compared to the total price of the medicine.
• Coinsurance: In some states, you might be required to pay a percentage of the cost of the medication. This payment, known as coinsurance, can vary based on several factors.

To find out what you might need to pay, check your state’s Medicaid drug list or contact your local Medicaid office.

How to get Entresto with Medicaid

If you qualify for Medicaid and need Entresto, here are the steps you can take to get the medication:

1. Talk to your healthcare provider. Discuss heart failure symptoms with your healthcare provider to see if Entresto is the proper treatment. If it is, your healthcare provider will write a prescription.
2. Wait for prior authorization, if required. If your state’s Medicaid program requires prior authorization, your healthcare provider must submit the necessary paperwork to Medicaid. This might include your medical history and the reasons why you need Entresto.
3. Fill the prescription: Once you have approval, you can take the prescription to your pharmacy to have it filled. Make sure the pharmacy accepts Medicaid.

Ways to get discounts on Entresto without Medicaid

There are ways to save on Entresto if Medicaid doesn’t cover Entresto in your state. For example, with a SingleCare prescription discount card, you gain access to digital coupons you can use at pharmacies across the country. With an Entresto coupon from SingleCare, you could pay $663 instead of $940 for a month’s supply, depending on the pharmacy you choose.   

There may also be Entresto alternatives you can take for heart failure, and some may have generic versions, which are often more affordable. 

Keep in mind that if you have both Medicare and Medicaid, you have dual eligibility. This means you may be able to use Medicaid to pay for things that Medicare won’t—although medications are often an exception to this rule. Additionally, starting in 2026, Medicare can negotiate with drug manufacturers for better pricing for some Medicare Part B and D drugs that don’t have competition. This includes Entresto. Until then, if you struggle to afford Entresto with Medicare, you can apply for the Part D Low Income Subsidy (LIS) program, also known as Extra Help. If you have both Medicare and Medicaid, you will qualify for Extra Help automatically.