Medicare Part D covers Breztri, but your out-of-pocket cost depends on your specific plan and which coverage stage you're in
Breztri is a combination inhaler used to treat chronic obstructive pulmonary disease (COPD). It contains three active ingredients: budesonide, glycopyrrolate, and formoterol. Most Medicare Part D prescription drug plans do cover Breztri, but whether it's affordable for you depends on your plan's formulary (the list of drugs it covers), your deductible, and where you fall in the coverage stages.
The amount you pay can change significantly depending on the time of year and how much you've spent on prescriptions. Some plans place Breztri in a higher cost tier, which means you'll pay more out of pocket. Others may require you to try a different COPD inhaler first before covering Breztri — a requirement called a step therapy or prior authorization.
Key Takeaways
- Breztri is covered by most Medicare Part D plans, but your cost depends on your plan's formulary tier and your current coverage stage.
- Your plan may require prior authorization or step therapy, meaning your doctor may need to document why other inhalers didn't work for you first.
- You can check your specific plan's coverage by reviewing your plan documents, calling your plan's customer service, or using the Medicare Plan Finder tool.
- If Breztri costs too much under your current plan, you can switch to a different Part D plan during the annual open enrollment period (October 15 to December 7).
- Once you reach the catastrophic coverage stage, Medicare pays most of the cost, though you'll still pay a small copayment per prescription.
How Medicare Part D coverage works for inhalers
Medicare Part D is the prescription drug benefit. It covers medications dispensed at pharmacies, including inhalers. Your coverage is not automatic — you must be enrolled in a Part D plan through a private insurance company that contracts with Medicare. If you have Original Medicare (Parts A and B) without a Part D plan, you do not have prescription drug coverage through Medicare.
Each Part D plan sets its own formulary and decides which tier (cost level) each drug falls into. Tier 1 drugs cost the least; Tier 5 drugs cost the most. Breztri is typically placed in Tier 3 or Tier 4, meaning it is not the cheapest option but not the most expensive either. However, this varies by plan and by year — your plan can change its formulary every January.
What determines your out-of-pocket cost for Breztri
Your cost for Breztri moves through four stages during the calendar year: the deductible stage, the initial coverage stage, the coverage gap (donut hole), and catastrophic coverage.
In the deductible stage, you pay the full cost of Breztri until you reach your plan's deductible amount (which varies by plan). Once you meet the deductible, you move to the initial coverage stage, where you pay a copayment or coinsurance (a percentage of the drug's cost). This is usually the stage where most people use their prescriptions during the year.
If your total prescription costs reach a certain threshold (the amount varies yearly), you enter the coverage gap, sometimes called the donut hole. In this stage, you pay a higher percentage of the drug's cost. However, manufacturer discounts and generic drug savings count toward closing the gap, so your actual out-of-pocket cost may be lower than it appears.
Once your out-of-pocket spending reaches the catastrophic threshold, Medicare pays most of the cost, and you pay only a small copayment per prescription for the rest of the year.
Prior authorization and step therapy for Breztri
Some Medicare Part D plans require prior authorization before they will cover Breztri. This means your doctor must submit a request to the plan explaining why you need this specific inhaler. The plan reviews the request and either approves or denies coverage.
Other plans use step therapy, which means the plan will only cover Breztri if you have already tried and failed to benefit from a cheaper COPD inhaler first. Your doctor documents this in your medical record and submits it with the prior authorization request. Step therapy can delay your access to Breztri by several weeks while you try another medication.
If your plan denies coverage or requires step therapy and you believe it is medically necessary, you have the right to request an appeal. Your doctor can help with this process by providing clinical evidence that Breztri is the right choice for your condition.
How to learn about your plan covers Breztri
The fastest way to check your coverage is to call your Part D plan's customer service number. This number is on your insurance card. Tell them you want to know the copayment or coinsurance for Breztri and whether the plan requires prior authorization. Write down the amount and any restrictions.
You can also review your plan's formulary online. Most plans post their formularies on their websites, organized by drug name. Search for "Breztri" and note which tier it is in and any notes about prior authorization or step therapy.
If you do not yet have a Part D plan and want to compare coverage before you enroll, use the Medicare Plan Finder tool on Medicare.gov. Enter Breztri as a drug you take, and the tool will show you which plans in your area cover it and what your estimated cost would be under each plan.
Switching plans if Breztri costs too much
If your current plan's copayment for Breztri is unaffordable, you can switch to a different Part D plan. The annual open enrollment period runs from October 15 to December 7 each year. During this time, you can drop your current plan and enroll in a new one that takes effect January 1.
Before you switch, use the Medicare Plan Finder to compare plans side by side. Look not only at the Breztri copayment but also at the plan's deductible, the copayments for other medications you take, and the plan's pharmacy network. A plan with a lower Breztri copayment might have a higher deductible or higher copayments for other drugs, so compare your total estimated costs.
If you miss the open enrollment period, you may still be able to switch if you may have access to for a special enrollment period. may have access to events include losing employer coverage, moving to a new state, or having a major life change. Contact Medicare at 1-800-MEDICARE to ask whether you may have access to.
Generic and alternative COPD inhalers
Breztri is a brand-name medication and does not have a generic version. However, other combination inhalers for COPD may cost less under your plan. These include Symbicort (budesonide and formoterol), Dulera (mometasone and formoterol), and Trelegy (fluticasone, umeclidinium, and vilanterol).
Your doctor may recommend one of these alternatives if Breztri is too expensive or if your plan requires step therapy. Each inhaler works slightly differently, so talk with your doctor about whether a lower-cost option would work for your COPD. Do not stop taking your current inhaler or switch without medical guidance.
Frequently Asked Questions
Does Medicare Part A or Part B cover Breztri?
No. Part A covers hospital care and Part B covers doctor visits and some medical equipment. Breztri is a prescription drug, so only Part D covers it. If you have Original Medicare without Part D, you will need to enroll in a Part D plan to have prescription coverage for Breztri.
What if I can't afford the copayment even after switching plans?
Ask your doctor's office about patient information programs run by the manufacturer. Many pharmaceutical companies offer copayment cards or free medication to people who meet income requirements. Your doctor's office or local health department can also refer you to community health centers that may offer medications at reduced cost.
Will my Breztri copayment stay the same all year?
No. Your copayment changes as you move through the coverage stages. It will be highest during the coverage gap stage and lowest during catastrophic coverage. Your plan's customer service can estimate what you'll pay at each stage based on your prescription history.
Can I use a GoodRx coupon or discount card instead of my Medicare plan?
You can, but it is usually not a good idea. Using a discount card means the cost does not count toward your deductible or out-of-pocket maximum, so you may end up paying more overall. Compare the discount price to your plan's copayment before you decide. If the discount is significantly lower, ask your pharmacist which option saves you more money in the long run.
What happens to my Breztri coverage if I switch from Part D to a Medicare Advantage plan?
Medicare Advantage plans (Part C) include prescription drug coverage, but each plan has its own formulary. Breztri may be covered, but the copayment and prior authorization requirements will be different. Review the Medicare Advantage plan's formulary before you switch to make sure Breztri is covered at an affordable cost.