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Insurance and Rybelsus

Rybelsus, the oral form of the breakthrough drug semaglutide, helps to lower blood glucose levels in adults with type 2 diabetes. Diabetes is a common but serious health condition and is becoming alarmingly prevalent at increasingly younger ages and higher rates.

Uncontrolled high blood sugar from unmanaged type 2 diabetes can lead to kidney damage, nerve problems, and vision loss, among other complications. Currently, diabetes is the 8th leading cause of death in the United States. Taking an effective diabetes medication can drastically improve your health, but it may hurt your wallet. The CDC has found that patients who have been diagnosed with diabetes spend about twice as much money on healthcare as patients without diabetes.

Health insurance is supposed to offset the costs of medical care to ensure people have access to the doctors and medications they need to stay healthy. However, as many people know from experience, it doesn’t cover every cost. If you are considering starting Rybelsus to treat your type 2 diabetes, here’s what you should know about insurance and the cost of Rybelsus.

How Much Does Rybelsus Cost With vs. Without Insurance?

In general, you will pay less for medications with insurance than without. However, how much you end up paying can vary based on several different factors. First of all, pharmacies are a business, and they want to make a profit. They have to pay to purchase medications from the manufacturer before they can. If the pharmacy were to sell the drug for the same price as they bought it or less, they would not make any money. Pharmacies can choose to mark up the price of products as much as they want without any regulation.

One factor affecting how much you’ll pay is the cost the pharmacy charges for the drug. The other factor is how much of that cost insurance will cover. This varies widely based on your insurance provider and the plan you have with them.
Health insurance companies and pharmacies work with a third party known as a pharmacy benefit manager (PBM) to negotiate reimbursement rates. PBMs often own their own pharmacies and negotiate with manufacturers for lower prices. Pharmacies benefit from working with health insurance companies because if the pharmacy is covered by that insurance company, the insurance company can direct its enrollees’ business toward that pharmacy. Manufacturers benefit by getting their products on the health insurance company’s formularies.

A formulary is a table that lists which drugs a health insurance plan covers. Formularies can have up to 5 tiers. Tier 1 represents the least expensive drugs, usually very common generic medications. You may pay nothing or only a few dollars for these drugs. As tiers increase, you can expect to pay more out of pocket. Depending on your prescription benefits, medications may not be covered until you reach a deductible. If you have reached your deductible but choose to get your medications from an out-of-network pharmacy or a “not preferred” pharmacy, you may still end up paying more.

Your insurance plan, their relationship with the pharmacy and manufacturer, and how much of your deductible you’ve spent can influence the final price you pay out of pocket for your Rybelsus prescription. According to the manufacturer’s website, some people may pay as little as $10 for their monthly refill with insurance. Others may pay more. Without insurance, a 30-day supply of the lowest dose of Rybelsus costs over $900. This is the 3mg starter dose. For a 30-day supply of the 7mg or 14 mg maintenance dose, costs can exceed $1200.

Will My Insurance Cover Rybelsus?

The good news is most commercial health insurance providers have included Rybelsus on their formularies. This means they are willing to cover at least some of the cost of medication. However, they may not cover costs for every patient but only ones for whom they deem it is “medically necessary.” Criteria to have your Rybelsus prescription covered by insurance may include:
  • A type 2 diabetes diagnosis
  • An allergy or other adverse reaction that requires you to discontinue use of other diabetes medications like lira glutide, injectable semaglutide, or metformin
  • Insufficient glycemic response to even the highest doses of insulin or other diabetes medications

Since semaglutide can cause thyroid tumors, some insurance companies may not cover Rybelsus for patients with a personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2, even if you meet other criteria.

If your insurance does not cover your Rybelsus prescription for any reason, you can always try to ask for an exception or write a letter of appeal.

Injectable forms of semaglutide like Wegovy and Ozempic have been shown to cause significant weight loss. Patients who want the weight loss benefits of semaglutide without having to inject themselves with a needle may be interested in taking Rybelsus for weight loss. However, Rybelsus has not been approved as a weight loss medication, but the FDA and most insurance companies will not cover drugs prescribed for off-label use.

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Coupons for Rybelsus

Even with insurance, a drug as expensive as Rybelsus can still cost more than patients are able to spend each month on a single medication. The manufacturer, Novo Nordisk, provides coupons to patients that can lower their out-of-pocket costs for Rybelsus. Unfortunately, these coupons are only available to those who are enrolled in a commercial health insurance plan. Patients enrolled in any state or federal government healthcare program like Medicare, Medigap, VA, DOD, or TRICARE are not eligible to use the manufacturer’s coupon.
With a coupon, patients may pay as little as $10 out of pocket for their Rybelsus prescription after insurance. The coupon is good for up to $300 off a 30-day supply, $600 off a 60-day supply, or $900 off a 90-day supply. The manufacturer may limit how long you can use the coupon, usually between 12 to 24 months.

Patient Assistance from Novo Nordisk

According to the CDC, adults living below the federal poverty line have the highest prevalence of diabetes out of the entire population. They are also the most likely to need government health insurance or have no insurance at all. Diabetes is also more common in older adults, especially those who are out of the workforce, no longer have an income, and rely on Medicare for health insurance. These vulnerable groups are not eligible for coupons, but they may be able to offset the costs of their medication through Novo Nordisk’s Patient Assistant Program (PAP). Through the PAP, uninsured or underinsured patients can get their medications at little to no cost. To qualify for Novo Nordisk’s PAP, you must meet the following criteria:
  • Be a citizen or legal resident of the United States
  • Live in a household with a total income below 400% of the federal poverty level
  • Receive Medicare or not have any insurance at all

Those enrolled in other government healthcare programs like Medicaid or VA Benefits are not eligible for Novo Nordisk’s PAP. If you qualify for Medicaid, you must sign a Patient Declaration denying Medicaid or Medicare Extra Help/LIS coverage.

Coupons and Patient Assistance may help some people afford Rybelsus, but they are far from perfect.

Government Insurance vs. Private Insurance

If you’ve tried to find information about the average cost of Rybelsus with insurance, you’ve probably encountered frustration. Unfortunately, there is not much information publicly available about the average cost of Rybelsus with insurance. However, given that with a coupon for $300 off a 30-day supply and some people can pay as little as $10 per month, it is reasonable to assume that the out-of-pocket costs are at least $300 to $400 for a 30-day supply. Patients using government health insurance may pay up to $1076 for a 30-day supply of pills. In general, studies have shown that patients using government health insurance pay more than twice as much in out-of-pocket costs for prescription medications as privately insured patients do, and they are more likely to have to pay out of pocket for high-cost drugs.
Private health insurance plans generally come with more expensive premiums than government health insurance plans, and only certain people are eligible for government health insurance based on their income, age, disability status, or employment.

Can I Save Money with a Generic Version?

Most of the time, generic versions of medications are less expensive, both with and without insurance. Not only are the generic versions of drugs less expensive than their brand-name counterparts, but insurance companies are likely to cover a greater percentage of the cost for a generic medication. However, not all brand-name medications have generic versions, including Rybelsus. When a pharmaceutical manufacturer develops a new drug, they receive patent protection for that drug. This means that no other company is allowed to make or sell the same drug. Patents can last for up to 20 years. Right now, Rybelsus is expected to retain its patent protections until at least 2029 and maybe as late as 2034. Until that time, there will be no less expensive generic versions of oral semaglutide available.

Why is Rybelsus so expensive?

In the United States, patients can easily end up paying over a thousand dollars a month for their Rybelsus prescription. Part of this is due to the drug itself. Semaglutide is an innovative new product that has only been developed in the past decade. Part of the high cost covers the research and development process that went into creating the drug and setting up new manufacturing processes and equipment. It has also proved highly effective at helping patients manage their blood sugar levels and lead healthier lives. The demand for an effective type 2 diabetes treatment is high, which drives up the cost of the drug if the price is not regulated.

This is the main difference between the US and other countries. In Canada or the European Union, patients can purchase Rybelsus for only a fraction of what it costs in the US because their governments regulate the prices pharmaceutical companies can charge for their products. In the US, pharmaceutical companies are free to set their own prices. Due to patent laws, Novo Nordisk has no competitors pressuring them to lower the price of their medication. If patients want oral semaglutide, they have to pay whatever price Novo Nordisk has set.

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