Prior authorization required

Does SCAN Health Plan require prior authorization for Rybelsus?

SCAN Health Plan 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	74 / 74	74	74	Prior authorization required
semaglutide 3 MG Oral Tablet [Rybelsus]2200654	74 / 74	74	74	Prior authorization required
semaglutide 7 MG Oral Tablet [Rybelsus]2200658	74 / 74	74	74	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
SCAN Affirm partnered with Included LGBTQ+ Health (HMO)	H5425-092	3	Yes	No	Yes
SCAN Affirm partnered with Included LGBTQ+ Health (HMO)	H5425-096	3	Yes	No	Yes
SCAN Affirm partnered with Included LGBTQ+ Health (HMO)	H5425-107	3	Yes	No	Yes
SCAN Allied (HMO)	H5425-118	3	Yes	No	Yes
SCAN Allied (HMO)	H5425-123	3	Yes	No	Yes
SCAN Alta (HMO)	H5425-082	3	Yes	No	Yes
SCAN Balance (HMO C-SNP)	H0978-002	3	Yes	No	Yes
SCAN Balance (HMO C-SNP)	H1822-002	3	Yes	No	Yes
SCAN Balance (HMO C-SNP)	H5244-002	3	Yes	No	Yes
SCAN Balance (HMO C-SNP)	H5425-034	3	Yes	No	Yes
SCAN Balance (HMO C-SNP)	H5425-070	3	Yes	No	Yes
SCAN Balance (HMO C-SNP)	H5425-076	3	Yes	No	Yes
SCAN Balance (HMO C-SNP)	H5425-102	3	Yes	No	Yes
SCAN Balance (HMO C-SNP)	H5425-104	3	Yes	No	Yes
SCAN Balance (HMO C-SNP)	H5425-105	3	Yes	No	Yes
SCAN Balance (HMO C-SNP)	H5425-106	3	Yes	No	Yes
SCAN Balance (HMO C-SNP)	H5425-129	3	Yes	No	Yes
SCAN Balance Texas (HMO C-SNP)	H8902-002	3	Yes	No	Yes
SCAN Classic (HMO)	H0978-001	3	Yes	No	Yes
SCAN Classic (HMO)	H1822-001	3	Yes	No	Yes
SCAN Classic (HMO)	H5244-001	3	Yes	No	Yes
SCAN Classic (HMO)	H5425-001	3	Yes	No	Yes
SCAN Classic (HMO)	H5425-005	3	Yes	No	Yes
SCAN Classic (HMO)	H5425-006	3	Yes	No	Yes
SCAN Classic (HMO)	H5425-007	3	Yes	No	Yes
SCAN Classic (HMO)	H5425-008	3	Yes	No	Yes
SCAN Classic (HMO)	H5425-009	3	Yes	No	Yes
SCAN Classic (HMO)	H5425-019	3	Yes	No	Yes
SCAN Classic (HMO)	H5425-069	3	Yes	No	Yes
SCAN Classic (HMO)	H5425-075	3	Yes	No	Yes
SCAN Classic (HMO)	H5425-101	3	Yes	No	Yes
SCAN Classic (HMO)	H5425-128	3	Yes	No	Yes
SCAN Classic Texas (HMO)	H8902-010	3	Yes	No	Yes
SCAN Classic WA (HMO)	H4026-001	3	Yes	No	Yes
SCAN Compass (HMO)	H5425-124	3	Yes	No	Yes
SCAN Connections (HMO D-SNP)	H0976-001	3	Yes	No	Yes
SCAN Connections at Home (HMO D-SNP)	H0976-002	3	Yes	No	Yes
SCAN Desert Choice (HMO)	H5425-135	3	Yes	No	Yes
SCAN Embrace (HMO I-SNP)	H5425-086	3	Yes	No	Yes
SCAN Embrace (HMO I-SNP)	H5425-087	3	Yes	No	Yes
SCAN Embrace (HMO-POS I-SNP)	H1822-005	3	Yes	No	Yes
SCAN Embrace (HMO-POS I-SNP)	H5425-091	3	Yes	No	Yes
SCAN Embrace Together (HMO I-SNP)	H5425-131	3	Yes	No	Yes
SCAN Embrace Together (HMO-POS I-SNP)	H1822-008	3	Yes	No	Yes
SCAN Embrace Together (HMO-POS I-SNP)	H5425-132	3	Yes	No	Yes
SCAN Essential Savings (HMO)	H5425-133	3	Yes	No	Yes
SCAN Inspired by women for women (HMO)	H5425-100	3	Yes	No	Yes
SCAN MyChoice (HMO)	H0978-011	3	Yes	No	Yes
SCAN MyChoice (HMO)	H1822-007	3	Yes	No	Yes
SCAN MyChoice (HMO)	H5244-005	3	Yes	No	Yes
SCAN MyChoice (HMO)	H5425-108	3	Yes	No	Yes
SCAN MyChoice (HMO)	H5425-109	3	Yes	No	Yes
SCAN MyChoice (HMO)	H5425-110	3	Yes	No	Yes
SCAN MyChoice (HMO)	H5425-119	3	Yes	No	Yes
SCAN MyChoice (HMO)	H5425-120	3	Yes	No	Yes
SCAN MyChoice (HMO)	H5425-121	3	Yes	No	Yes
SCAN MyChoice (HMO)	H5425-130	3	Yes	No	Yes
SCAN MyChoice Texas (HMO)	H8902-011	3	Yes	No	Yes
SCAN MyChoice WA (HMO)	H4026-002	3	Yes	No	Yes
SCAN Prime (HMO)	H5425-065	3	Yes	No	Yes
SCAN Select (HMO)	H5425-134	3	Yes	No	Yes
SCAN Strive (HMO C-SNP)	H0978-010	3	Yes	No	Yes
SCAN Strive (HMO C-SNP)	H1822-006	3	Yes	No	Yes
SCAN Strive (HMO C-SNP)	H5244-004	3	Yes	No	Yes
SCAN Strive (HMO C-SNP)	H5425-097	3	Yes	No	Yes
SCAN Strive (HMO C-SNP)	H5425-098	3	Yes	No	Yes
SCAN Strive Texas (HMO C-SNP)	H8902-009	3	Yes	No	Yes
SCAN Venture (HMO)	H5425-084	3	Yes	No	Yes
SCAN Venture (HMO)	H5425-085	3	Yes	No	Yes
Sutter Senior Advantage, a SCAN Medicare Plan (HMO)	H5425-125	3	Yes	No	Yes
Sutter Senior Advantage, a SCAN Medicare Plan (HMO)	H5425-126	3	Yes	No	Yes
Sutter Senior Advantage, a SCAN Medicare Plan (HMO)	H5425-127	3	Yes	No	Yes
VillageHealth (HMO-POS C-SNP)	H5943-003	3	Yes	No	Yes
VillageHealth (HMO-POS C-SNP)	H5943-004	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.