Is Breztri covered by Medicaid?

In this article:

• Does Medicaid cover Breztri?
• Factors influencing coverage
• How much does Breztri cost?
• Costs of Breztri with Medicaid
• Ways to get discounts on Breztri

In this article

• Does Medicaid cover Breztri?
• Factors influencing coverage
• How much does Breztri cost?
• Costs of Breztri with Medicaid
• Ways to get discounts on Breztri

For many people, breathing is second nature. But for people with chronic obstructive pulmonary disease (COPD), it’s not nearly as easy. That’s where Breztri Aerosphere comes in. This three-in-one inhaler combines a corticosteroid (budesonide), an anticholinergic (glycopyrrolate), and a long-acting beta2-adrenergic agonist (formoterol fumarate) to improve breathing and reduce COPD flare-up symptoms.

It’s a powerful medication, but that power can come at a cost. And while the specific price depends on several factors, it may leave patients wondering if they’ll get any help from Medicaid. Usually, yes, although the out-of-pocket costs can vary. Here are all the important details.   

Does Medicaid cover Breztri?

Most of the time, Medicaid will cover Breztri. But since Medicaid is jointly funded by the state and federal governments, each state has different policies and eligibility requirements. Typically, patients have to meet certain household income requirements, but the exact amounts can vary by state.

Factors influencing Medicaid coverage of Breztri 

There are two major factors that determine whether a Medicaid plan will cover Breztri: the preferred drug list (PDL) and prior authorization requirements.

Preferred drug list

Even though most Medicaid beneficiaries will get at least some coverage for Breztri, it may depend on where you live. Each state has a Preferred Drug List (PDL), which shows how its Medicaid plans will cover different prescription drugs.

These lists typically categorize drugs as preferred or nonpreferred, and they can vary in how they classify Breztri. Some states may have budget restrictions, so they might prioritize covering cheaper alternatives. However, Breztri does not have a cheaper generic alternative, so some states may list it as a preferred drug. Some states might also have quantity limits, which restrict the amount of medication a patient can get in a certain time frame. 

Prior authorization

Sometimes, insurance plans require additional steps before approving coverage, to ensure a certain drug is medically necessary—a process called prior authorization. “For Breztri, prior authorization usually requires showing that the medication is medically necessary. Medicaid often asks for evidence such as recent pulmonary function tests to confirm moderate to severe COPD,” says Michael Genovese, MD, JD, chief medical adviser at Ascendant New York. “Additionally, doctors typically need to document that the patient has tried other therapies—like long-acting bronchodilators or inhaled corticosteroids—and explain why those treatments weren’t effective or caused side effects.” 

The process of trying other medications first is called step therapy, and some plans require it. For example, one of Dr. Genovese’s patients had severe COPD and needed Breztri, “but faced delays because Medicaid required proof that other treatments had been tried and failed,” he says. “We had to submit detailed documentation, including medical records, test results, and notes about the patient’s symptoms and responses to previous medications.”

But prior authorization can move smoothly if the patient and healthcare provider communicate well. Dr. Genovese says he always advises patients to stay proactive. “Ensure your healthcare provider knows your medication history, including any past prescriptions that didn’t work for you,” he says. “Keep your records organized and readily available. Following up with your healthcare provider’s office or Medicaid representative can help prevent unnecessary delays.”

How much does Breztri cost?

When paying for Breztri completely out of pocket—without insurance, Medicare, or Medicaid coverage—the average price is $877 for an inhaler with a 30-day supply of medication. 

That price may change, though, depending on your dosage and pharmacy. Drug prices between pharmacies, even ones in the same community, can vary by potentially hundreds of dollars.

Costs of Breztri with Medicaid

Once again, Breztri’s specific out-of-pocket cost is based on how much a particular Medicaid plan will cover. That said, “for Medicaid beneficiaries, Breztri is often very affordable,” Dr. Genovese says. In fact, AstraZeneca, the manufacturer of Breztri, says most people with Medicaid will pay $0.99–$1.35 per month, and “some states may even waive copays entirely for certain beneficiaries. Reviewing your specific Medicaid plan to understand your exact out-of-pocket costs is essential.”

For example, for people enrolled in Michigan’s Medicaid fee-for-service plan, pharmacy copays are $1 for preferred drugs and $3 for nonpreferred drugs. Breztri is nonpreferred and requires prior authorization for coverage, but beneficiaries who are dually eligible for Medicare and Medicaid are exempt from these fees. The state’s Department of Health and Human Services notes, however, that some Medicaid health plan copays may differ.

That’s just one example, and there are 49 other states that may handle Breztri coverage differently, so be sure to check your formulary for details.

Ways to get discounts on Breztri

Not everyone pays full price for Breztri Aerosphere. One of the easiest and most effective ways to save on Breztri is to use a SingleCare coupon. It’s free to sign up for a SingleCare prescription discount card and access coupons you can use at local participating pharmacies. However, you can’t use SingleCare coupons on top of Medicaid coverage.

Patients can also apply for discounts directly from Breztri’s manufacturer, AstraZeneca. If you have private insurance that doesn’t cover Breztri’s full cost, you might be eligible for Breztri Zero Pay, which might reduce out-of-pocket costs to as low as $0 per month. However, you can’t enroll if you receive prescription drug coverage from any government-sponsored programs, including Medicare and Medicaid. If you’re uninsured or have Medicare or Medicaid and need additional help paying for Breztri—you may be eligible for AstraZeneca’s broader patient assistance program, AZ&Me.

Additionally, “If your healthcare provider approves, ask about a 90-day prescription,” Dr. Genovese recommends. “Pharmacies often offer discounts on larger quantities, reducing the per-month cost.” It might also be worth calling around to local pharmacies to find the lowest prices on Breztri, since prices can vary significantly between them.