COMBIVENT RESPIMAT 20/100 ug Spray, Metered

Also known as Ipratropium Bromide And Albuterol. Coverage in Missouri (CMS PDP Region 18).

10 of 10 stand-alone Part D plans in Missouri cover this drug on tier 3–4.

10 of 10 plans apply a prior authorization, step therapy or quantity limit.

141 Medicare Advantage plans in MO 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. MO: 141 plans.

Every plan that covers it

Plan	Tier	30-day preferred	90-day mail	Unit cost	Est. 30-day fill	Restrictions
Wellcare Value Script (PDP)$9.60/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$119.8656	$958.928 units	Quantity limit 8 per 30 days
Wellcare Classic (PDP)$10.70/mo premium · $615.00 deductible	3Preferred Brand	25%	25%	$119.8656	$958.928 units	Quantity limit 8 per 30 days
AARP Medicare Rx Saver from UHC (PDP)$71.90/mo premium · $615.00 deductible	3Preferred Brand	17%	17%	$132.9020	$797.416 units	Quantity limit 4 per 20 days
AARP Medicare Rx Preferred from UHC (PDP)$125.40/mo premium · $130.00 deductible	3Preferred Brand	17%	17%	$132.9020	$797.416 units	Quantity limit 4 per 20 days
Humana Basic Rx Plan (PDP)$16.50/mo premium · $615.00 deductible	4Non-Preferred Drug	35%	—	$124.0343	$744.216 units	Quantity limit 4 per 20 days
Humana Value Rx Plan (PDP)$33.70/mo premium · $601.00 deductible	4Non-Preferred Drug	34%	—	$124.0343	$744.216 units	Quantity limit 4 per 20 days
HealthSpring Extra Rx (PDP)$70.70/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$121.9991	$975.998 units	Quantity limit 8 per 30 days
HealthSpring Assurance Rx (PDP)$74.30/mo premium · $615.00 deductible	4Non-Preferred Drug	30%	30%	$121.9954	$975.968 units	Quantity limit 8 per 30 days
SilverScript Choice (PDP)$94.90/mo premium · $615.00 deductible	4Non-Preferred Drug	33%	33%	$128.0692	$1,024.558 units	Quantity limit 8 per 30 days
Humana Premier Rx Plan (PDP)$126.40/mo premium · $0.00 deductible	4Non-Preferred Drug	50%	50%	$124.0343	$744.216 units	Quantity limit 4 per 20 days

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.

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