Medicare Coverage for Breztri: The Short Answer

Medicare Part D covers Breztri (budesonide/glycopyrrolate/formoterol), a maintenance inhaler for chronic obstructive pulmonary disease (COPD), but the amount you pay depends on your specific plan and which tier the drug sits on. Most plans place Breztri on Tier 3 or Tier 4, meaning you will pay a higher copay than you would for a generic or preferred brand-name drug. The drug itself is not covered by Part A or Part B — only by prescription drug plans.

Whether your out-of-pocket cost is manageable depends on three things: your plan's formulary (the list of covered drugs), your plan's cost-sharing structure, and whether you have reached the coverage gap or catastrophic phase of your benefit year. You can find the exact copay for your plan by checking your plan documents or calling the plan directly.

Key Takeaways

  • Breztri is covered by most Medicare Part D plans, but usually as a Tier 3 or Tier 4 drug, which means higher copays than generic alternatives.
  • Your actual copay amount varies by plan and changes depending on which phase of the benefit year you are in — initial coverage, coverage gap, or catastrophic.
  • Some plans may require prior authorization or step therapy, meaning your doctor must show you have tried other COPD inhalers first.
  • You can compare Breztri costs across plans during the annual Medicare open enrollment period (October 15 to December 7) using Medicare.gov's plan finder tool.
  • Patient information programs run by the manufacturer may reduce your copay if your income falls below certain thresholds.

How Medicare Part D Covers Breztri

Part D plans cover Breztri as a prescription medication, but not all plans cover it the same way. Each plan creates its own formulary — a list of covered drugs organized by tier. Tier 1 drugs cost the least (usually generic), Tier 2 drugs cost more (preferred brands), and Tiers 3 and 4 cost the most. Breztri typically lands on Tier 3 or Tier 4 because it is a newer, brand-name combination inhaler.

When you fill a Breztri prescription, you pay a copay set by your plan. That copay is not the same as the drug's actual price — it is your share of the cost. The plan pays the rest. Your copay amount depends on which phase of the benefit year you are in. During the initial coverage phase, you pay your standard copay. Once you and your plan have spent a combined $5,850 on covered drugs in 2024 (this amount changes yearly), you enter the coverage gap, where you pay a higher percentage of the drug's cost. Once you reach $8,550 in out-of-pocket spending, you enter catastrophic coverage, where you pay a small copay again.

What Your Copay Might Be

Copays for Tier 3 and Tier 4 drugs range widely — typically $35 to $100 per month or more, depending on your plan. Some plans use coinsurance instead of a flat copay, meaning you pay a percentage of the drug's cost (often 25% to 33%). You will not know your exact copay until you check your specific plan's formulary.

The fastest way to find out is to call your plan's customer service number (on the back of your Medicare card) and ask: "Is Breztri on your formulary, and what is the copay for a 30-day supply?" Have your plan name and member ID ready. You can also log into your plan's website and search the formulary directly, or use Medicare.gov's plan finder tool if you are comparing plans during open enrollment.

Prior Authorization and Step Therapy Requirements

Some Part D plans require prior authorization before they will cover Breztri, meaning your doctor must submit a request to the plan explaining why you need this specific drug. Other plans use step therapy, which means the plan will only cover Breztri after you have tried and failed on a cheaper alternative (usually a generic COPD inhaler like albuterol or ipratropium).

If your plan has either requirement, your doctor's office typically handles the paperwork. However, this can delay your prescription by a few days to a week. Ask your doctor's office to check your plan's requirements before you fill the prescription so there are no surprises at the pharmacy. If the plan denies coverage, you have the right to appeal — your doctor can submit additional medical information to support the request.

Manufacturer information and Copay Cards

AstraZeneca, the manufacturer of Breztri, offers a copay information program for patients with Medicare Part D coverage. If your household income is below a certain threshold (typically around $50,000 to $75,000 for an individual, though this varies), you may be able to reduce your copay to as little as $0 to $10 per month.

To learn about you may have access to, visit the manufacturer's patient information website or call their support line. You will need to provide proof of income and Medicare enrollment. The information program is separate from your insurance plan — it works alongside your Part D coverage. Some programs also offer a copay card that you can use at the pharmacy to lower your out-of-pocket cost when ready.

Comparing Plans During Open Enrollment

If your current plan's copay for Breztri is too high, you can switch to a different Part D plan during the annual open enrollment period, which runs from October 15 to December 7 each year. Changes take effect January 1.

Use the Medicare Plan Finder tool at Medicare.gov to compare plans side by side. Enter Breztri as a drug you take, and the tool will show you which plans cover it, what the copay is, and what your total estimated costs would be for the year. You can filter by copay amount, pharmacy network, and other factors. Keep in mind that plan formularies and copays change every year, so even if you are happy with your current plan, it is worth checking during open enrollment to see if a better option is available.

What Happens If Your Plan Does Not Cover Breztri

If your Part D plan does not cover Breztri at all, you have several options. First, ask your doctor if there is a similar generic or preferred brand-name COPD inhaler that your plan does cover — your doctor may be able to switch you without loss of effectiveness. Second, you can request a formulary exception from your plan, asking them to cover Breztri anyway. Your doctor must submit this request with medical justification.

Third, you can switch to a different Part D plan during open enrollment that does cover Breztri. Fourth, you can pay out of pocket for Breztri without using insurance — the cash price is typically $300 to $400 per month, though the manufacturer's copay information program may reduce this. If cost is the main barrier, talk to your doctor and pharmacist about all these options before deciding.

Frequently Asked Questions

Does Medicare Part A or Part B cover Breztri?

No. Part A covers hospital stays and Part B covers doctor visits and some equipment, but neither covers prescription drugs. Only Part D prescription drug plans cover Breztri. If you do not have Part D, you will pay the full cost out of pocket unless you may have access to for the manufacturer's information program.

Will my copay change if I reach the coverage gap?

Yes. During the coverage gap (also called the "donut hole"), you pay a higher percentage of the drug's cost, usually 25% to 33% of the price, rather than your standard copay. Once you reach catastrophic coverage, your copay drops again. The exact amounts depend on your plan and change yearly.

Can I use a GoodRx coupon instead of my Medicare plan?

You can, but you should compare prices first. Using a GoodRx coupon means you are not using your insurance, so the cost does not count toward your Part D deductible or out-of-pocket maximum. In some cases, your Part D copay will be lower than the GoodRx price; in others, it will be higher. Ask your pharmacist to show you both prices before you decide.

What if my doctor prescribed a different brand of the same drug?

If your doctor prescribed a different COPD inhaler (such as Symbicort or Dulera), your Part D plan may cover it at a lower copay. Ask your doctor if switching is medically appropriate for you. If Breztri is the only option your doctor recommends, request a formulary exception from your plan or ask about the manufacturer's copay information program.

Can I appeal if my plan denies coverage for Breztri?

Yes. You have the right to appeal any coverage denial. Your doctor can submit additional medical information explaining why Breztri is medically necessary for you. The plan must respond to your appeal within 72 hours for urgent requests or 30 days for standard requests. If the plan denies the appeal, you can request an independent review through Medicare.