Is Quviviq covered by Medicare?

In this article:

• Does Medicare cover Quviviq? 
• Factors influencing Medicare coverage of Quviviq 
• How much does Quviviq cost?
• Other options if Medicare doesn't cover Quviviq

In this article

• Does Medicare cover Quviviq? 
• Factors influencing Medicare coverage of Quviviq 
• How much does Quviviq cost?
• Other options if Medicare doesn't cover Quviviq

Sleep can improve our mood, productivity, and overall health—but for some people, catching Z’s is easier said than done. Enter Quviviq (daridorexant), a brand-name drug approved by the Food and Drug Administration (FDA) to treat insomnia (trouble falling asleep or staying asleep). The cost of Quviviq is based on several factors, and perhaps the most influential is insurance coverage. Medicare rarely covers Quviviq, but it depends on the specific Part D plan and your reason for taking it. We’ve got all the additional information you need about the medication’s Medicare coverage here. 

Does Medicare cover Quviviq? 

Medicare Part D plans cover plenty of prescription drugs. But unfortunately, that rarely includes Quviviq. Ani Rostomyan, Pharm.D., CEO and founder of SheAni Wellness, said, “From my own pharmacy experience, Quviviq was not covered by my patients’ Medicare part D plans.” In fact, she said she only remembers one instance when an insurance provider approved a prior authorization request, and it was after a healthcare provider submitted the request on a patient’s behalf based on medical necessity.

These plans will sometimes cover other sleep medications, but it depends entirely on the plan. That said, data from the Centers for Medicare & Medicaid Services shows that Medicare Part D plans spent over $2 million covering Quviviq in 2022, so some plans may help pay in certain instances.

To know for sure whether your specific plan covers Quviviq, check your plan’s formulary—a drug list that shows whether and how the plan covers each medication. For example, it may cover some medications entirely, while it might require beneficiaries to pay copays or coinsurance for others. And, different plans also sometimes involve various types of restrictions, such as monthly quantity limits. Every plan’s formulary is different, so it’s important to review yours before beginning treatment.

You’ll notice we didn’t mention Medicare Part A or Part B, and that’s because they generally don’t include coverage for drugs taken outside of a hospital or doctor’s office. Medicare Advantage (Part C) often comes bundled with drug coverage, but not always.

Factors influencing Medicare coverage of Quviviq 

One of the biggest factors Medicare plans might take into consideration is the reason your healthcare provider prescribed Quviviq. For example, the insurance provider might see it as more necessary for someone with a diagnosed case of chronic insomnia than mild transient insomnia. 

To confirm whether Quviviq is truly medically necessary, some Medicare plans may require prior authorization before they approve coverage. That might mean the healthcare provider has to submit paperwork confirming the patient’s diagnosis, or it might mean the patient has to try less expensive medications first—a process called step therapy. 

How much does Quviviq cost?

So what should you expect to pay for Quviviq without help from Medicare or other insurance? The average cash price is $634.75 for 30, 50 mg tablets. That price stems largely from the cost required to develop new drugs. A study from 2020 estimated that it costs around $600 million–$1.2 billion to bring a new drug to market, accounting for all research, development, and clinical trials. 

Approved in 2022, Quviviq is a relatively new drug, so “its pharmaceutical company, Idorsia Pharmaceuticals, is the patent holder and has the exclusive rights to exclude others from making, using, and selling the drug,” said Tiffany Khieu, Pharm.D, an assistant professor at Marshall B. Ketchum University. “When patents expire, other companies can produce generic versions of the drug, which can influence costs,” but as of right now, there’s no generic version of Quviviq.

That said, $634.72 is an average—not a hard and fast price. The price each patient pays is subject to numerous influences. For example, prescription drug costs can vary significantly between pharmacies—sometimes by hundreds of dollars—since each pharmacy sets its own prices. 

Cost of Quviviq with Medicare

As we mentioned, not everyone with Medicare Part D will get their Quviviq covered, but some might. Unfortunately, not all of those patients will walk away with free medications. They may still have some out-of-pocket costs (like copays and deductibles) based on their plan’s cost-sharing policies. The total amount of those costs will vary, depending on the specific plan, so be sure to confirm your plan’s fee structures if you receive coverage.  

Other options if Medicare doesn’t cover Quviviq

So, if Medicare and insurance companies can’t help, then what? Quviviq’s full price may seem intimidating, but there are several ways to save money on your prescription. Here are a few of the most reliable.

1. Apply for a Quviviq copay card

Idorsia Pharmaceuticals doesn’t have a patient assistance program that covers Quviviq, but it offers a discount card program called QSavings. People who have private health insurance plans—but whose plan doesn’t cover the full cost of Quviviq—can use this card to get their first fill for as little as $0, then subsequent refills of a 30-day supply for as low as $25. However, it doesn’t apply to uninsured patients or anyone who receives federally funded prescription drug coverage from Medicare, Medicaid, Medigap, Veterans Affairs (VA), or Department of Defense (DOD) programs.

2. Get free SingleCare coupons

These discounts are available to anyone and can help decrease the price of prescription drugs at participating pharmacies. For example, a SingleCare coupon can reduce Quviviq’s average monthly retail price from $634.75 to $488.34. You can access these discounts even if you have Medicare or insurance coverage, but you can’t use both of them together.

3. Consider an alternative

There’s no shortage of sleep aids on the market, so if you’re willing to try a different one (and your healthcare provider signs off), you’ve got plenty of options. “Per the American Academy of Sleep Medicine’s insomnia guidelines for adults, there are alternatives with different mechanisms of action to treat insomnia,” Dr. Khieu said. “However, their level of evidence for efficacy is relatively weak, and benefits versus risks must be taken into consideration for each individual patient.”

Drugs like Belsomra and Dayvigo are also relatively new and only available in brand-name formulations, but other alternatives have been around long enough to have FDA-approved generic versions, which often come at a lower cost. For example, zolpidem (generic Ambien) can go for as low as $2.11 per one-month supply when you use a SingleCare coupon, depending on your choice of pharmacy. Over-the-counter supplements like melatonin, CBD, and certain vitamins might also work for some people. “There are also non-pharmaceutical options, such as sleep hygiene, that can improve sleep prior to medication use,” Dr. Khieu said.

RELATED: Quviviq vs. Belsomra

4. Research other assistance programs

Those who put in the legwork can find other assistance programs around the internet—and some of the most effective come from the government and nonprofits. Medicare beneficiaries might be eligible for the Extra Help program, and for anyone with private insurance, the Patient Advocate Foundation’s Co-Pay Relief program might help as well. Just know that you’ll have to meet specific eligibility requirements to qualify.

5. Locate cheaper pharmacy options

Driving across town isn’t always the most appealing option if you’ve got a jam-packed schedule, but if it can help you save on your drug costs, it might just be worthwhile. In fact, a study from the U.S. Public Interest Research Group found patients could save up to $5,400 per year by shopping around for the lowest price. Prices can vary by hundreds between pharmacies, even within the same vicinity, so call around to see which local pharmacy offers the best rates on Quviviq.