Is Gemtesa covered by Medicare?

In this article:

• Does Medicare cover Gemtesa?
• Why is it sometimes not covered?
• Strategies for getting coverage
• Alternatives covered by Medicare
• Cost with Medicare
• How to save
• The bottom line

In this article

• Does Medicare cover Gemtesa?
• Why is it sometimes not covered?
• Strategies for getting coverage
• Alternatives covered by Medicare
• Cost with Medicare
• How to save
• The bottom line

People with overactive bladder (OAB) syndrome received another treatment option when Gemtesa (vibegron) hit the market in 2020. However, as with many other new medications, some people learned that their health insurance didn’t cover the cost of Gemtesa. With Medicare, drug costs, including the cost of Gemtesa, often depend on the recipient’s supplemental drug coverage.

Here’s what to know if you have Medicare and want to take Gemtesa to address OAB, but are concerned about the price.

Save up to 80% on Gemtesa with SingleCare

Different pharmacies offer different prices for the same medication. SingleCare helps find the best price for you.

Gemtesa 75 mg (30 Tablets)

23666 - Hampton, VA

$427.20

i Price with signup

Get free coupon

$427.20

i Price with signup

Get free coupon

See Gemtesa prices at all pharmacies

Does Medicare cover Gemtesa?

Gemtesa is designed to treat overactive bladder (OAB) in adults, as well as adult males who are also taking medicine for benign prostatic hyperplasia (BPH).

Sometimes Medicare covers the cost of Gemtesa, and sometimes it doesn’t.

“From my experience, coverage has really broadened over the past year, but it still varies by plan,” says Dr. Erika Alexander, Pharm.D., a clinical pharmacist with MOBE.

“Vibegron has been a great addition—very effective, very well tolerated, and without the drug interaction issues we sometimes see with mirabegron. My patients often like it,” says Dr. Justin Houman, MD, urologist and surgeon, comparing vibegron to another OAB treatment that is marketed under the brand-name Myrbetriq. “The challenge is coverage,” he adds.

In fact, a recent study in the journal Urogynecology (Phila) found that beta-3 adrenergic agonists, which include both vibegron and mirabegron, tend to have the worst insurance coverage nationwide.

Why is it sometimes not covered?

Prescription drug coverage can vary widely, depending on the type of insurance you have and its drug formulary. Sometimes, insurance plans only cover certain medications within a particular category, or they may not cover a specific medication if less expensive alternatives are already available.

People who have Medicare can get prescription drug coverage, or Medicare Part D, in one of two ways:

• Add on Medicare Part D to your original Medicare coverage, which includes hospital coverage (Part A) and medical coverage (Part B)
• Choose a Medicare Advantage Plan that combines parts A, B, and D into a single plan.

Like other types of insurance plans, Medicare prescription drug plans each have their own lists of medications that they cover. Generally, Medicare plan drug formularies cover a wide range of medications typically used by Medicare patients. The drugs are categorized into tiers, ranging from the lowest to the highest price. It can vary by plan, which means that Medicare coverage for Gemtesa may also vary.

Medicare.gov explains that drug lists must contain at least two drugs in the most commonly prescribed categories and classes. However, the plans get to choose which ones within those categories they cover, so your plan might not cover one specific drug, but it will cover a similar medication.

According to Dr. Houman, you will have to check your formulary to see if it specifically covers Gemtesa.

“Some Medicare Part D plans cover it, but many either don’t, or they place it in a higher specialty tier, making it costly,” he says. “So while it’s clinically an excellent choice, access can be inconsistent, depending on the patient’s plan.”

Strategies for getting Gemtesa covered by Medicare

Here are several strategies that may help you gain access to Gemtesa that fit within your budget:

Check your plan’s formulary

Not sure if your plan’s formulary covers Gemtesa? Check the formulary. The best time to review your formulary is during the annual Open Enrollment Period, according to Dr. Alexander. If your current plan does not cover Gemtesa, you can switch to a different plan the following year.

“The Medicare website has a tool that can be used to input your medications and find the plan that works best for you,” Dr. Alexander says, adding that pharmacists are a good resource for assistance with this process, too.

Submit a prior authorization request

Doctors can submit a prior authorization request to a Medicare plan to ask for coverage for Gemtesa. Prior authorization is essentially a request made in advance for an insurance plan to cover the cost of a drug or procedure. The healthcare provider makes the case for why the medication is necessary, and the insurance plan reviews the request before issuing a decision.

“Typically, insurers want to see that the patient has either failed or not tolerated at least two formulary alternatives,” Dr. Houman explains. “I’ll outline risks like cognitive decline from anticholinergics or hypertension with mirabegron.”

Look into Extra Help

Another possible option that can help some Medicare beneficiaries pay for prescription medications, such as Gemtesa, is the Extra Help program. Extra Help was created to assist Medicare recipients with limited income in paying for their Medicare Part D premiums, deductibles, coinsurance, and other costs.

“If you’re on Medicare, it’s a great idea to check whether you qualify for the Extra Help program,” Dr. Alexander says.

Some people qualify automatically, while others who are eligible may have to apply for the coverage. More information about Extra Help applications is available on the U.S. Social Security Administration website.

Try the step approach

Some Medicare Part D plans require that patients try step therapy before the plan will cover a particular medication. This involves trying a less expensive drug for a particular medical condition on your plan’s formulary first before the plan considers covering a more expensive medication. Some plans even require starting with a generic version of a drug, then stepping up to a less-expensive brand-name drug, before they’ll agree to cover a more expensive brand-name drug.

“That just means your provider might need to document why you need it or show that you’ve tried other bladder medications first,” Dr. Alexander says.

Appeal a denial

If you receive a denial for the coverage of Gemtesa, you have the option to appeal the denial. According to Medicare.gov, you can contact your plan to appeal for a coverage decision for a prescription drug. With a Coverage Determination Request, you can ask to get repaid for a drug that you’ve already bought, or you can ask for coverage for a drug you haven’t already received.

Alternative OAB medications covered by Medicare

Gemtesa is just one of a number of prescription OAB treatments.

“According to the American Urological Association, the treatment of choice for overactive bladder (OAB) are antimuscarinic agents, such as oxybutynin, and beta-3 agonists, such as vibegron,” says Dr. Jonathan Newsome, Pharm.D., professor of clinical sciences at High Point University’s Fred Wilson School of Pharmacy. “The antimuscarinic agents are older, cheaper medications compared to the beta-3 agonists. This results in the antimuscarinics being more commonly prescribed.”

Dr. Newsome explains that mirabegron is generally less expensive than vibegron, as it was approved by the U.S. Food and Drug Administration (FDA) in 2012, whereas vibegron was approved in 2020.

If your Medicare plan formulary does not cover Gemtesa and you’re concerned about the potential costs, your healthcare provider might suggest looking at some of the alternatives, which each have their own specific use, side effect profile, and dosage:

• Myrbetriq (mirabegron extended-release (ER))
• Oxybutynin chloride ER
• Vesicare (solifenacin succinate)
• Detrol (tolterodine tartrate)
• Tolterodine ER
• Darifenacin ER
• Toviaz (fesoterodine fumarate ER)
• Trospium chloride

Another possibility is Botox (botulinum toxin) injections, which can help effectively manage OAB in older adults. However, research suggests that careful post-injection monitoring is necessary due to a potential increased risk for urinary tract infections (UTIs) and urinary retention.

Two other third-line options for OAB are percutaneous tibial nerve stimulation and sacral neuromodulation. These are covered by Medicare when standard therapies fail and can be good options for people who want to avoid medication, according to Dr. Houman.

Cost of Gemtesa with Medicare

The average retail price of Gemtesa without insurance is $673 for 30, 75 mg tablets, which is a 30-day supply. However, the actual cost that someone ends up paying will vary depending on their choice of plan and the medications covered by the formulary. Each Medicare Part D plan has its own drug formulary, including both brand-name and generic drugs. The specific plan determines the cost of a particular medication.

How to save on Gemtesa

If your insurance plan does not specifically cover Gemtesa, you could investigate other drugs that could help you manage OAB. However, it may also be possible to pursue strategies that help you gain access to Gemtesa at a lower cost.

One option is to use the SingleCare prescription discount card. With the card, you may be able to receive coupons that discount the cost of Gemtesa enough to fit it into your budget.

The manufacturer of Gemtesa also offers the Gemtesa Simple Savings Program to eligible, commercially-insured patients. Some people whose insurance covers Gemtesa may qualify for a free 90-day supply, while others may qualify to pay only $10 per month. Those without Gemtesa insurance coverage may be eligible to pay only $95 per month.

 Medicare and Medicaid recipients do not qualify for the Gemtesa Simple Savings Program. However, once they hit their out-of-pocket max for their plan, they may not have to pay any additional costs for medications.

The bottom line

Some drugs can be pricier than others that target the same condition. That could be the case when it comes to Gemtesa costs. Medicare recipients don’t have to necessarily give up on their Gemtesa prescription, though. They can consult with their healthcare provider to discuss their best options and explore potential ways to reduce the cost of Gemtesa.