01-07-2025
Does Medicare Cover Gemtesa?
Medicare should cover drugs for treating overactive bladder (OAB), such as Gemtesa. But whether this particular medication is covered varies depending on your specific plan.
Gemtesa (vibegron) is a brand-name pill that helps treat OAB and falls under the beta-3 adrenergic agonist category.
In Medicare, prescription drugs are covered by private Medicare Part D plans, which you can purchase in addition to Original Medicare (Parts A and B).
You also have the option to enroll in a Medicare Advantage (Part C) plan, which is a private insurance plan that replaces Original Medicare. Some Part C plans offer drug coverage, and these are called Medicare Advantage Prescription Drug (MAPD) plans.
Read on to learn about coverage of Gemtesa under your drug plan coverage options with Medicare.
Is Gemtesa covered by Medicare Part D?
Either Medicare Part D or MAPD plans can cover Gemtesa. Because these are private plans, each insurer will have its own list of covered drugs called a formulary. Whether or not your specific plan covers this drug depends on whether it's included in this list.
That said, because OAB is a common condition, many Medicare drug plans should cover Gemtesa or an effective alternative.
In fact, Medicare drug plans are required to cover at least two drugs from each commonly prescribed drug category. So, even if your plan doesn't cover Gemtesa, it should cover another alternative medication from the same category.
What does Gemtesa cost with and without Medicare?
In general, 30 tablets of Gemtesa can cost around $500 without insurance. But the price might vary depending on the pharmacy you get it from.
If you're on Medicare and your drug plan includes this medication, your out-of-pocket costs, or copayment, will depend on how the drug is classified in your plan's formulary. Usually, the higher the classification tier, the more you'll end up paying, while generic drugs are typically placed in the lower tiers.
There's no generic version of Gemtesa. So, in 2025, your total out-of-pocket expenses for medications through Medicare are capped at $2,000.
It's important to remember that since Part D and MAPD plans are run by private insurers, your deductibles, premiums, and copays can differ by plan.
In 2025, the national base beneficiary premium for Part D is set at $36.78, and the average monthly premium for Medicare Advantage plans is around $17, according to the Centers for Medicare & Medicaid Services (CMS).
Is there a Gemtesa Medicare patient assistance program?
You may have the option to enroll in the Gemtesa Simple Savings program, which is offered by the drug's manufacturer and could help you get the drug at a lower price.
Usually, you can't combine manufacturer drug discount programs with Medicare coverage. But, depending on your specific plan, getting Gemtesa through this program might be cheaper than through Medicare.
To see if you're eligible, call 833-876-8268 or visit the program website. The Medicine Assistance Tool and NeedyMeds are other resources that might help you save on prescription drugs.
Are there alternatives to Gemtesa through Medicare?
Myrbetriq (mirabegron) is another beta-3 agonist that doctors often prescribe for OAB and may also be covered by Medicare.
A 2022 study comparing Myrbetriq and Gemtesa found that, after 52 weeks, Gemtesa showed a significant improvement in reducing daily urinary incontinence episodes.
But it's important to remember that both Myrbetriq and Gemtesa can have side effects. Consult with your doctor to decide which option suits you best, considering your Medicare coverage.
Also, keep in mind that your drug plan might need prior authorization before covering Gemtesa. This could involve step therapy, which means trying a different, effective, and more affordable medication first.
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