Prior authorization required

Does Bravo Health Pennsylvania, INC. require prior authorization for Rybelsus?

Bravo Health Pennsylvania, INC. requires prior authorization for Rybelsus on every Medicare Part D plan of theirs that covers it.

Every plan from this payer that covers the drug requires authorization before it is dispensed.

By product strength

RxNorm product	Plans covering	Require prior auth	Qty limit	Status
semaglutide 14 MG Oral Tablet [Rybelsus]2200650	35 / 35	35	35	Prior authorization required
semaglutide 3 MG Oral Tablet [Rybelsus]2200654	35 / 35	35	35	Prior authorization required
semaglutide 7 MG Oral Tablet [Rybelsus]2200658	35 / 35	35	35	Prior authorization required

Product names come from RxNorm (U.S. National Library of Medicine).

Plan-by-plan detail — semaglutide 14 MG Oral Tablet [Rybelsus]

Rybelsus has 3 products in the corpus; this table is for semaglutide 14 MG Oral Tablet [Rybelsus], the one carried on the most plans. The product table above covers every strength.

Plan	Contract	Tier	Prior auth	Step therapy	Qty limit
HealthSpring Achieve (HMO C-SNP)	H0354-027	6	Yes	No	Yes
HealthSpring Achieve (HMO C-SNP)	H3949-024	6	Yes	No	Yes
HealthSpring Alliance (HMO)	H0354-028	3	Yes	No	Yes
HealthSpring Preferred (HMO)	H0354-001	3	Yes	No	Yes
HealthSpring Preferred (HMO)	H3949-035	3	Yes	No	Yes
HealthSpring Preferred (HMO)	H3949-045	3	Yes	No	Yes
HealthSpring Preferred (HMO)	H3949-047	3	Yes	No	Yes
HealthSpring Preferred (HMO)	H3949-049	3	Yes	No	Yes
HealthSpring Preferred (HMO)	H3949-052	3	Yes	No	Yes
HealthSpring Preferred (HMO)	H3949-054	3	Yes	No	Yes
HealthSpring Preferred (HMO)	H9725-009	3	Yes	No	Yes
HealthSpring Preferred (HMO)	H9725-009	3	Yes	No	Yes
HealthSpring Preferred (HMO)	H9725-009	3	Yes	No	Yes
HealthSpring Preferred (HMO)	H9725-009	3	Yes	No	Yes
HealthSpring Preferred Full Savings (HMO)	H0354-030	3	Yes	No	Yes
HealthSpring Preferred PA (HMO)	H3949-031	3	Yes	No	Yes
HealthSpring Preferred Plus (HMO)	H3949-030	3	Yes	No	Yes
HealthSpring Preferred Plus (HMO)	H3949-048	3	Yes	No	Yes
HealthSpring Preferred Plus (HMO)	H9725-017	3	Yes	No	Yes
HealthSpring Preferred Plus (HMO)	H9725-017	3	Yes	No	Yes
HealthSpring Preferred Plus (HMO)	H9725-017	3	Yes	No	Yes
HealthSpring Preferred Plus (HMO)	H9725-017	3	Yes	No	Yes
HealthSpring Preferred Savings (HMO)	H0354-029	3	Yes	No	Yes
HealthSpring Preferred Savings (HMO)	H3949-053	3	Yes	No	Yes
HealthSpring Preferred Savings (HMO)	H9725-015	3	Yes	No	Yes
HealthSpring Preferred Savings (HMO)	H9725-015	3	Yes	No	Yes
HealthSpring Preferred Savings (HMO)	H9725-015	3	Yes	No	Yes
HealthSpring Preferred Savings (HMO)	H9725-015	3	Yes	No	Yes
HealthSpring Preferred Savings (HMO)	H9725-016	3	Yes	No	Yes
HealthSpring Preferred Select (HMO)	H9725-014	3	Yes	No	Yes
HealthSpring Premier (HMO-POS)	H9725-018	3	Yes	No	Yes
HealthSpring TotalCare (HMO D-SNP)	H9725-003	3	Yes	No	Yes
HealthSpring TotalCare Plus (HMO D-SNP)	H2752-003	3	Yes	No	Yes
HealthSpring TotalCare Plus (HMO D-SNP)	H3949-009	3	Yes	No	Yes
HealthSpring TotalCare Plus (HMO D-SNP)	H9725-013	3	Yes	No	Yes

Source

Monthly Prescription Drug Plan Formulary and Pharmacy Network Information — Basic Drugs Formulary File

Effective: 2026-06-30
Retrieved: 2026-07-19
SHA-256: e626e6bcda1aa6a0071e6f0df6bafe686ae41842cdf0a9feffdc649b6d3ff3ae

We publish the hash of the exact file we ingested so any answer can be audited against the bytes CMS served that day.

Rybelsus at other payers

Or see Rybelsus across every payer at once.

Administrative information only. Benefily reports what a payer has published in its own prior-authorization policy as of the effective date shown. It is not medical advice, not a coverage or payment guarantee, and not an authorization. Requirements vary by plan, place of service and member benefits — always verify with the payer before rendering service.