BREZTRI 160/9/4.8 ug Aerosol, Metered
Also known as Budesonide, Glycopyrrolate, And Formoterol Fumarate. Coverage in Hawaii (CMS PDP Region 33).
7 of 8 stand-alone Part D plans in Hawaii cover this drug on tier 3.
Lowest 30-day cost $45.00 at a preferred pharmacy. 7 of 7 plans apply a prior authorization, step therapy or quantity limit.
30 Medicare Advantage plans in HI do cover it
Medicare Advantage plans carry their own formularies, separate from stand-alone Part D. A patient on an MA-PD plan may have coverage even where no PDP lists the drug. HI: 30 plans.
Every plan that covers it
| Plan | Tier | 30-day preferred | 90-day mail | Unit cost | Est. 30-day fill | Restrictions |
|---|---|---|---|---|---|---|
| Humana Basic Rx Plan (PDP)$0.40/mo premium · $615.00 deductible | 3Preferred Brand | 23% | 18% | $61.8678 | $680.5511 units |
|
| SilverScript Choice (PDP)$14.70/mo premium · $615.00 deductible | 3Preferred Brand | 19% | 19% | $63.0311 | $693.3411 units |
|
| Wellcare Value Script (PDP)$21.60/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $58.3656 | $642.0211 units |
|
| Wellcare Classic (PDP)$21.70/mo premium · $615.00 deductible | 3Preferred Brand | 25% | 25% | $58.3656 | $642.0211 units |
|
| Humana Value Rx Plan (PDP)$51.60/mo premium · $601.00 deductible | 3Preferred Brand | 20% | 15% | $61.8678 | $680.5511 units |
|
| Humana Premier Rx Plan (PDP)$90.20/mo premium · $0.00 deductible | 3Preferred Brand | $45.00 | $125.00 | $61.8678 | $680.5511 units |
|
| AARP Medicare Rx Preferred from UHC (PDP)$139.20/mo premium · $130.00 deductible | 3Preferred Brand | 17% | 17% | $64.7352 | $712.0911 units |
|
Cost-sharing is the initial coverage phase at a preferred pharmacy; a percentage is coinsurance of the plan’s negotiated price, and the deductible may apply first. CMS publishes a negotiated price per unit, so the 30-day fill is shown only where the plan’s own quantity limit supplies the quantity.