Medicare Part D covers Rybelsus, but only if your plan includes it and you meet the plan's cost-sharing rules

Rybelsus (semaglutide) is a diabetes medication taken by mouth, not injection. Medicare Part D — the prescription drug coverage part of Medicare — can cover it, but whether yours does depends on your specific plan. Each Part D plan maintains its own formulary, which is the list of drugs it will pay for. Some plans cover Rybelsus with no restrictions; others require you to try a different diabetes drug first, or charge a higher copay or coinsurance.

The coverage question is not whether Medicare covers the drug in general — it does — but whether your plan covers it at the cost level you can afford. This matters because Rybelsus costs roughly $300 to $400 per month without insurance, and the difference between a $10 copay and a $100 copay changes whether the drug is practical for you.

Key Takeaways

  • Medicare Part D covers Rybelsus through most plans, but your specific plan's formulary determines whether it is covered and at what cost to you.
  • Some plans require step therapy — meaning you must try and fail on a cheaper diabetes drug first before Rybelsus is covered.
  • You can check your plan's coverage by calling the plan directly, visiting its website, or using the Medicare Plan Finder tool on Medicare.gov.
  • If your plan does not cover Rybelsus or charges too much, you can switch to a different Part D plan during the annual open enrollment period (October 15 to December 7).
  • The manufacturer offers a copay card that can reduce your out-of-pocket cost to as little as $25 per month if you have commercial insurance or Medicare Part D.

How to check if your Part D plan covers Rybelsus

Start by finding your plan's formulary. You can do this three ways. First, log into your plan's website — most plans have a drug search tool where you type "Rybelsus" and it shows you the tier (cost level) and any restrictions. Second, call your plan's customer service number, which is on your insurance card. Have your card handy and ask directly: "Does my plan cover Rybelsus, and what is my copay?" Third, use the Medicare Plan Finder on Medicare.gov. Enter your zip code, select your current plan, and search for Rybelsus in the drug search box.

When you find the information, note three things: whether the drug is covered at all, what tier it is on (tier 1 is cheapest, tier 5 is most expensive), and whether there are restrictions like step therapy or prior authorization. Step therapy means the plan will only cover Rybelsus after you have tried and failed on a cheaper drug — usually metformin or another first-line diabetes medication. Prior authorization means the plan requires your doctor to submit paperwork proving medical necessity before they will pay.

What step therapy means and how to get around it

If your plan uses step therapy for Rybelsus, it will not pay for the drug until you have taken a different diabetes medication for a set period — often 30 to 90 days — and your doctor documents that it did not work or caused side effects. This is a cost-control measure: the plan wants you to try cheaper options first.

If you and your doctor believe Rybelsus is medically necessary without trying another drug first, your doctor can request an exception. This is called a formulary exception or step therapy override. Your doctor submits a letter to the plan explaining why the step therapy requirement should be waived — for example, if you have already tried the required drug in the past, or if you have a medical reason to avoid it. The plan typically responds within 72 hours. Many exceptions are granted, especially if your doctor provides clinical justification.

Cost-sharing: copays, coinsurance, and the donut hole

Your out-of-pocket cost for Rybelsus depends on your plan's structure. Most plans charge a copay — a flat fee per prescription, often $10 to $50 depending on the tier. Some plans use coinsurance instead, meaning you pay a percentage of the drug's cost, typically 20% to 33%. A few plans use a combination.

Rybelsus also interacts with Medicare's coverage gap, sometimes called the donut hole. Once you and your plan have spent $5,380 on covered drugs in 2024 (this amount changes yearly), you enter the gap and pay more out of pocket until your total out-of-pocket spending reaches $7,050. After that, catastrophic coverage kicks in and you pay only 5% of the cost. However, the manufacturer's copay card often covers your cost during the gap, so you may not feel the impact.

Using the manufacturer's copay card

Novo Nordisk, which makes Rybelsus, offers a copay card that reduces your cost to $25 per month if you have Medicare Part D or commercial insurance. You can find the card on the Rybelsus website or ask your doctor's office for one. The card is free and works at most pharmacies.

There are limits: the card typically covers up to $300 per month in copay information, and it does not work if your plan does not cover Rybelsus at all. If your plan requires step therapy or prior authorization, the copay card does not bypass those requirements — your doctor still has to complete the approval process first. Once the drug is approved, the card reduces what you pay at the pharmacy.

Switching plans if Rybelsus is not covered or too expensive

If your current Part D plan does not cover Rybelsus, charges a very high copay, or requires step therapy you want to avoid, you can switch to a different plan. The annual open enrollment period runs from October 15 to December 7 each year. During this window, you can change your Part D plan, and the new coverage starts January 1.

Use the Medicare Plan Finder to compare plans side by side. Filter by your state and zip code, then search for Rybelsus in each plan's formulary. Look for plans that cover it at tier 1 or 2 (lowest cost) with no step therapy. You can also call 1-800-MEDICARE to speak with a counselor who can help you compare plans. If you miss the annual window, you may still switch if you have a may have access to life event — such as moving, losing other insurance, or a change in your health status — but these are limited.

What to do if your doctor prescribes Rybelsus but your plan denies it

If your plan denies coverage, you have the right to appeal. Your doctor can submit a request for reconsideration, and if that is denied, you can file a formal appeal with the plan. The appeals process typically takes 30 to 60 days. Your doctor's office usually handles this paperwork, but you can also contact your plan directly to start the appeal.

While the appeal is pending, you have options. You can pay out of pocket for the medication — the copay card reduces the cost to $25 per month. You can ask your doctor if a different diabetes drug covered by your plan would work for you. Or you can wait until the next open enrollment period and switch plans. If you are in financial hardship, some pharmaceutical information programs offer free or reduced-cost medication; your doctor's office or a social worker can help you find these.

Frequently Asked Questions

Does Medicare Part A or Part B cover Rybelsus?

No. Part A covers hospital care and Part B covers doctor visits and some outpatient services. Rybelsus is a prescription drug, so only Part D covers it. If you do not have Part D, you can add it during the annual enrollment period or if you have a may have access to life event.

What if I cannot afford the copay even with the manufacturer's card?

Ask your doctor about patient information programs run by Novo Nordisk or other nonprofits. These programs provide free or low-cost medication to people who meet income requirements. Your doctor's office, a social worker, or a 211 helpline can connect you to these resources.

Can I use GoodRx or another discount card instead of my Medicare plan?

You can, but it is usually not the best choice. Medicare rules say you cannot use a discount card and your Part D coverage at the same time. If the discount price is lower than your copay, you might pay out of pocket with the discount card, but this does not count toward your deductible or out-of-pocket maximum, so it may cost you more in the long run.

Will my coverage change if I switch from Part D to a Medicare Advantage plan?

Medicare Advantage plans (Part C) include prescription drug coverage, but each plan has its own formulary. Some cover Rybelsus and some do not. If you are thinking about switching to Medicare Advantage, check the plan's drug coverage for Rybelsus before you enroll.

What happens to my Rybelsus coverage if I move to a different state?

Your current Part D plan may not be available in your new state. You will need to choose a new plan in your new state during the annual open enrollment period, or when ready if you move. Use the Medicare Plan Finder to see which plans cover Rybelsus in your new location.