Medicare Coverage for Yupelri

Yupelri (revefenacin) is covered by Medicare Part D, the prescription drug plan, but only if your plan includes it on its formulary — the list of drugs the plan will pay for. Whether you pay a copay, coinsurance, or the full price depends on which tier your plan places Yupelri on and which stage of the benefit year you are in. Not every Part D plan covers Yupelri, and coverage rules change each year, so you need to check your specific plan's formulary before you assume it will be covered.

Yupelri is a long-acting anticholinergic inhaler used to treat chronic obstructive pulmonary disease (COPD). It is a brand-name medication, which typically means higher out-of-pocket costs than generic alternatives. Some plans may require you to try a different COPD medication first, or to get prior authorization from the plan before they will pay for Yupelri.

Key Takeaways

  • Yupelri is covered by Medicare Part D, but only if your specific plan's formulary includes it — you must check your plan documents or call the plan to confirm.
  • Your out-of-pocket cost depends on which tier Yupelri is on and whether you have met your deductible or entered the coverage gap.
  • Some Part D plans require prior authorization or step therapy (trying another drug first) before they will cover Yupelri.
  • If your plan does not cover Yupelri, you can switch to a different Part D plan during the annual open enrollment period (October 15 to December 7) or request a coverage exception from your current plan.

How to Check If Your Plan Covers Yupelri

The fastest way to find out is to call your Part D plan directly. The phone number is on your insurance card. Tell them you take Yupelri and ask whether it is on their formulary, what tier it is on, and whether prior authorization is required. Write down the answers — you may need them later.

You can also check online. Log into your plan's website and search the formulary by drug name. Most plans let you filter by tier, which shows you what your copay or coinsurance will be. If you cannot find the formulary online or do not have your login, call the plan's customer service line.

If your plan does not list Yupelri on the formulary at all, ask whether a generic version of revefenacin is covered, or whether the plan covers other long-acting anticholinergic inhalers like Spiriva or Seebri. Your doctor may be able to switch you to a covered alternative.

Understanding Part D Tiers and Your Out-of-Pocket Cost

Part D plans organize drugs into tiers, usually four or five levels. Tier 1 (generic drugs) has the lowest copay. Tier 2 (preferred brand-name drugs) costs more. Tier 3 and Tier 4 (non-preferred brands and specialty drugs) have the highest copays or coinsurance. Yupelri is typically placed on Tier 3 or Tier 4 because it is a brand-name medication.

Your actual cost also depends on where you are in the benefit year. From January through your deductible, you pay the full price. Once you meet the deductible, you pay your copay or coinsurance. If you reach the coverage gap (also called the "donut hole"), you pay a higher percentage until you hit the catastrophic coverage threshold. After that, Medicare pays most of the cost.

The dollar amounts for deductibles, copays, and the coverage gap change every year. Check your plan's 2024 or 2025 Summary of Benefits document for exact figures.

Prior Authorization and Step Therapy Requirements

Some Part D plans require prior authorization before they will cover Yupelri. This means your doctor must contact the plan and get approval before you fill the prescription. The plan reviews your medical history to confirm the drug is medically necessary. This usually takes a few business days.

Other plans use step therapy, which means you must try a different COPD medication first and show that it did not work or caused side effects before the plan will cover Yupelri. Step therapy can delay your access to the medication you need, but you can ask your doctor to request an exception if you have a medical reason to skip the first drug.

Ask your plan whether either of these requirements applies to Yupelri. If they do, your doctor's office can usually handle the paperwork, but it is worth confirming that they are willing to do so before you fill the prescription.

What to Do If Your Plan Does Not Cover Yupelri

If Yupelri is not on your plan's formulary, you have three main options. First, ask your doctor whether a covered alternative COPD medication would work for you. Many plans cover other long-acting inhalers, and your doctor may be able to switch you without difficulty.

Second, request a coverage exception from your plan. You or your doctor can submit a written request explaining why Yupelri is medically necessary for you and why other covered drugs are not suitable. The plan has 72 hours to respond. If they deny the exception, you can appeal.

Third, switch to a different Part D plan. You can change plans during the annual open enrollment period, which runs from October 15 to December 7 each year. Use the Medicare Plan Finder tool on Medicare.gov to compare plans and see which ones cover Yupelri. If you have a may have access to life event (such as losing other insurance), you may be able to switch outside the open enrollment period.

Paying Out of Pocket Without Insurance

If you do not have Part D coverage or your plan does not cover Yupelri, you can pay cash. The retail price is typically $300 to $400 per month, depending on your pharmacy. Ask your pharmacy whether they offer a discount program or whether a generic version of revefenacin is available at a lower price.

Yupelri's manufacturer, Mylan, offers a patient information program that may reduce or eliminate your cost if your income is below a certain threshold. Ask your doctor's office or pharmacist how the process works, or visit the manufacturer's website.

Frequently Asked Questions

Does Medicare Part B cover Yupelri?

No. Part B covers medications given in a doctor's office or hospital setting, not medications you use at home. Yupelri is an inhaler you use yourself, so it is covered only by Part D (prescription drug coverage), not Part B.

Will I pay the same copay for Yupelri every month?

Not necessarily. Your copay depends on which tier Yupelri is on and which stage of the benefit year you are in. Once you reach the coverage gap, your copay increases. Once you reach catastrophic coverage, Medicare pays most of the cost and your copay drops again.

Can I get Yupelri covered if my doctor says it is medically necessary?

Yes, through a coverage exception. You or your doctor can request one in writing, explaining why Yupelri is necessary and why other covered drugs will not work. The plan must respond within 72 hours. If denied, you can appeal the decision.

What if I switch Part D plans — will my new plan cover Yupelri?

Not automatically. Each plan has its own formulary. Before you switch, use the Medicare Plan Finder to check whether the new plan covers Yupelri and what tier it is on. Switching plans takes effect on January 1 if you enroll during open enrollment.

Is there a cheaper alternative to Yupelri that Medicare covers?

Possibly. Other long-acting anticholinergic inhalers like Spiriva (tiotropium) and Seebri (glycopyrrolate) are often covered by Part D plans and may have lower copays. Ask your doctor whether one of these would work for your COPD.