Medicare Part D covers Yupelri, but only if your plan includes it on its formulary

Yupelri (abacavir sulfate) is a prescription medication used to treat chronic obstructive pulmonary disease (COPD). Whether Medicare pays for it depends on which Part D plan you have — not all plans cover this drug, and the ones that do may require you to meet certain conditions first, such as prior authorization or a step therapy requirement.

Your Part D plan publishes a list called a formulary that shows which drugs it covers. Yupelri appears on some formularies but not others. Even when it is covered, your plan may require your doctor to document that you have tried other COPD medications first, or to get approval before the pharmacy fills your prescription.

Key Takeaways

  • Yupelri coverage varies by Part D plan — check your plan's formulary or call the plan directly to confirm whether it is covered.
  • Your plan may require prior authorization, meaning your doctor must request approval from the insurance company before you can fill the prescription.
  • Some plans use step therapy, which means you may need to try a different COPD medication first and show it did not work for you.
  • If your current plan does not cover Yupelri, you can switch to a different Part D plan during the annual enrollment period (October 15 to December 7) or if you may have access to for a special enrollment period.

How to learn about your specific plan covers Yupelri

The fastest way is to call your Part D plan's customer service number, which is on your insurance card. Tell them you want to know whether Yupelri is on their formulary and whether your doctor will need to get prior authorization before the pharmacy can fill it. Write down the answers — you may need them when you talk to your doctor.

You can also look up your plan's formulary online. Go to your plan's website and search for "formulary" or "drug list." Most plans let you search by drug name. If you cannot find it online or the website is unclear, calling is faster than searching.

If you do not yet have a Part D plan and are trying to choose one, use the Medicare Plan Finder tool at Medicare.gov. Enter Yupelri in the drug search box, and the tool will show you which plans in your area cover it and what your out-of-pocket cost would be under each plan.

What prior authorization and step therapy mean for you

If your plan covers Yupelri but requires prior authorization, your doctor must contact the insurance company and get written approval before the pharmacy can fill your prescription. This usually takes a few business days. Your doctor's office handles the request — you do not need to do anything except make sure your doctor knows you want to use Yupelri.

Step therapy is different. It means your plan will only pay for Yupelri if you have already tried one or more other COPD medications and they did not work well enough for you. Your doctor documents this in your medical record, then requests approval. Step therapy can add weeks to the process, so if your doctor thinks Yupelri is the right first choice for you, ask them to request an exception — some plans will waive the step therapy requirement if your doctor explains why.

What Yupelri costs under Medicare Part D

Your out-of-pocket cost depends on which Part D plan you have and which tier (cost level) the plan places Yupelri on. Some plans put it on a higher tier, meaning you pay more. Others may put it on a lower tier. The Medicare Plan Finder tool shows the actual cost under each plan in your area.

Remember that Part D has a coverage gap (sometimes called the "donut hole"). Once you and your plan have spent a combined total of $5,850 on covered drugs in 2024, you enter the gap and pay a higher percentage of the cost until you reach the out-of-pocket spending limit. The exact amounts change each year. If Yupelri is a medication you will take long-term, ask your pharmacist or plan whether you will hit the gap, because that affects your total yearly cost.

What to do if your plan does not cover Yupelri

You have two main options. First, ask your doctor whether a different COPD medication that your plan does cover would work for you. Many people do well on other inhalers, and switching may be simpler than changing insurance plans.

Second, you can switch to a different Part D plan that does cover Yupelri. You can make this change during the annual enrollment period, which runs from October 15 to December 7 each year. Changes take effect January 1. If you have a may have access to life event — such as losing other insurance, moving to a new state, or becoming newly may be able to access for Medicare — you may be able to switch outside the enrollment period through a special enrollment period.

If you need Yupelri urgently and your current plan does not cover it, talk to your doctor about whether a temporary supply of a covered alternative is safe while you arrange a plan change.

How to request an exception if your plan denies coverage

If your plan initially denies coverage of Yupelri — either because it is not on the formulary or because prior authorization was denied — you have the right to request an exception. Your doctor must submit a written request explaining why Yupelri is medically necessary for you and why other covered alternatives would not work.

The plan has 72 hours to respond to an expedited exception request (if your health is at risk) or 14 days for a standard request. If the plan denies the exception, you can appeal to an independent reviewer outside the insurance company. Your plan's customer service line can walk you through the exception and appeal process.

Yupelri and other Medicare coverage

If you have Original Medicare (Part A and Part B) without a Part D plan, Yupelri is not covered — Part D is the only Medicare benefit that covers prescription drugs. You would need to enroll in a Part D plan or a Medicare Advantage plan that includes drug coverage (most do).

If you have a Medicare Advantage plan (Part C), drug coverage is included, but the plan's formulary may be different from standalone Part D plans. Check your Advantage plan's formulary the same way you would check a Part D plan's — call the plan or search online.

Frequently Asked Questions

Does Medicare Part B cover Yupelri?

No. Part B covers some injectables and infusions given in a doctor's office or hospital, but Yupelri is an inhaled medication you use at home. Only Part D covers it.

What if I cannot afford the copay for Yupelri?

Ask your doctor or pharmacist about patient information programs run by the drug manufacturer. Many pharmaceutical companies offer free or reduced-cost medication to people who meet income requirements. Your pharmacist can help you find and enroll in these programs.

Can I use a GoodRx coupon or discount card instead of my Part D plan?

You can, but it usually costs you more. Once you use your Part D coverage, the cost counts toward your deductible and out-of-pocket maximum, which helps you reach the coverage gap and eventually get catastrophic coverage. Using a discount card instead skips that progress. Compare the actual price under your Part D plan versus the discount card price before you decide.

What happens to my Yupelri coverage if I switch Part D plans?

It depends on the new plan. Some plans cover Yupelri and some do not. Before you switch, use the Medicare Plan Finder to confirm that your new plan covers it. If it does not, you can switch again during the next enrollment period or request an exception from the new plan.

Is there a generic version of Yupelri that might be cheaper?

Yupelri does not have a generic equivalent yet. Ask your doctor whether other COPD inhalers — some of which do have generic versions — might work for you and cost less under your plan.