Breztri prior authorization: What to do if insurance requires it or denies it

In this article:

• What is prior authorization?
• Why do insurance companies require prior authorization?
• How to get prior authorization
• What to do if your prior authorization is denied
• How to get Breztri while waiting for prior authorization
• Expert takeaway
• Frequently asked questions

In this article

• What is prior authorization?
• Why do insurance companies require prior authorization?
• How to get prior authorization
• What to do if your prior authorization is denied
• How to get Breztri while waiting for prior authorization
• Expert takeaway
• Frequently asked questions

Breztri Aerosphere (budesonide/glycropyrrolate/formoterol fumarate) is a brand-name inhaler that’s been approved by the Food and Drug Administration (FDA) as a daily maintenance treatment for chronic obstructive pulmonary disease (COPD) in adults. It’s also been FDA approved for daily use in people 12 and older with asthma. Many insurance companies require prior authorization before they’ll approve Breztri, and this can be a frustrating roadblock. Whether your prior authorization request has been denied or you’re waiting on a lengthy decision, you don’t have to go without Breztri in the meantime.

What is prior authorization for Breztri?

Prior authorization means your health insurance company has denied your medication and requires additional information from your healthcare provider before it agrees to cover the cost of Breztri.

Every insurance company uses a different checklist to decide whether to approve a prior authorization request for Breztri.

For example, here’s what Kaiser Permanente requires:

• A pulmonologist wrote the prescription.
• The patient is an adult and diagnosed with COPD.
• At least one of the following is true:
  • The patient has already tried a combination of inhaled corticosteroid (ICS), long-acting anti-cholinergic (LAMA), and long-acting beta agonist (LABA) administered through separate inhalers for at least 30 days, and this therapy failed, didn’t work, or produced intolerable side effects.
  • The patient can’t take other IC, LAMA, and LABA medications due to potential drug interactions or other contraindications.
• The prescriber can explain why using separate inhalers won’t work for the patient.

On the other hand, some Aetna plans use the following prior authorization criteria for Breztri:

• The patient is an adult and diagnosed with COPD.
• The patient filled a 30-day prescription for dual-therapy ICS and LABA (or LABA and LAMA) dual-therapy within the last 130 days.
• At least one of the following is true:
  • The dual-therapy medication isn’t working.
  • The patient has a blood eosinophil count of at least 300 cells/microliter and has experienced at least two moderate COPD exacerbations (or has been hospitalized for COPD at least once) in the last year.
• Breztri isn’t being prescribed as a rescue inhaler.
• You can see that different insurance plans require different prior authorization requirements. Your healthcare provider may require an appointment with you to adequately address all of the prior authorization requirements your insurance requires.

Your healthcare provider can access the prior authorization requirements for your specific healthcare plan.

Why do insurance companies require prior authorization for Breztri?

Health insurance companies tend to require prior authorization for Breztri because it’s a high-cost medication with no generic alternative. When a medication is expensive, insurance companies want to pay less. They want to know if another, less-expensive medication might work instead.

If you haven’t tried a Breztri alternative yet, your insurance company may require a step-therapy program. This means you must try certain types of medications (and sometimes in a specific order) to demonstrate that they don’t work for you.

Your healthcare provider may be able to explain why Breztri step therapy isn’t right for you, but many insurance companies prefer documented proof of step therapy failure.

How do you get prior authorization for Breztri?

Prior authorization is handled by your healthcare provider and the insurance company. Patients have little to no involvement. Here’s how it works.

Step 1: Your healthcare provider submits a PA request

Your healthcare provider will receive a prior authorization alert after sending your Breztri prescription to the pharmacy. They’ll fill out a form provided by your insurance company. If there is information that they do not know, then an appointment with the physician may be arranged to make sure that the insurance prior authorization form is filled out fully and accurately.

Consider following up with your healthcare provider to confirm that the prior authorization form has been sent.

Step 2: The insurer reviews the request

Next, the insurance company reviews the information and compares it to the coverage criteria that your individual insurance has formulated. Standard prior authorization requests can take about one week to process, while urgent requests should be resolved in less than 72 hours.

You, your healthcare provider, and your pharmacy will be notified once a decision has been made.

Step 3: The pharmacy notifies you to pick up the prescription

Once your Bretzi prescription has been approved, the pharmacy will prepare it and call you when it’s ready. Many pharmacies also call their customers when a prior authorization request has been denied. This way, you’ll know what to expect at checkout.

What to do if your prior authorization is denied

If your prescription was denied, a prior authorization form was completed and submitted, and even then, your request was denied, call your insurance company to find out why. Then, ask your healthcare provider to submit an appeal letter with specific additional documentation that your insurance requires. Prior authorization appeals don’t always work, but they’re worth a try.

If you’re repeatedly denied, talk to your healthcare provider about other covered prescriptions you can try instead. Consider changing insurances when you have open enrollment.  You can also use a SingleCare coupon for Breztri or see if you’re eligible for the AstraZeneca patient assistance program to lower Breztri’s out-of-pocket cost.

How to get Breztri while waiting for prior authorization

Breztri prior authorization requests should be processed quickly (within about 72 hours) because untreated COPD flare-ups may lead to increased respiratory issues, urgent care visits, or hospitalization. But sometimes there are delays. Here’s what you can do to get Breztri while waiting for prior authorization approval and pharmacy filling a medication.

1. Use a SingleCare coupon as a bridge. A free SingleCare prescription discount card gives you access to Breztri coupons you can use at pharmacies near you to lower the cash price of Breztri by about 39%. It can’t be combined with insurance, so the price you pay won’t count toward your deductible. Compare current prices at pharmacies near you on the Breztri coupon page.
2. Use separate inhalers. Breztri’s three active ingredients can be purchased in separate inhalers. While this isn’t as convenient as using a combination inhaler like Breztri, it may work short-term. Talk to your healthcare provider about the different options available, and use SingleCare coupons to lower the cost.
3. Ask about manufacturer assistance programs. You may be eligible to get Breztri for low or no cost through AstraZeneca’s savings programs. Breztri Zero Pay is for people with commercial insurance, and AZ&ME is for Medicare beneficiaries. Note that applications can take several days to process.
4. Ask your healthcare provider about samples. A Breztri sample has about one week’s worth of medication. Some healthcare providers keep these on hand so patients can start treatment while waiting for prior authorization.

Expert takeaway

Leslie Greenberg, MD, associate professor for Community and Family Medicine at the University of Nevada, Reno Family Medicine Residency and member of the SingleCare Medical Review Board, notes that “Breztri is very expensive, but necessary for many patients with COPD.  Most insurance companies do not want to pay for Breztri and make it difficult to obtain the medication and use cumbersome prior authorizations to deny, or at least delay treatment. Look into more affordable medicines or consider changing insurance plans.”

Frequently asked questions

Does Breztri require prior authorization?

It depends on your insurance plan. Some require prior authorization for Breztri, but others don’t.

Is Breztri available as a generic?

No, Breztri isn’t available as a generic. Based on patent expiration dates, generic Breztri isn’t likely to arrive until 2030 at the earliest. However, you can get generic versions of two of Breztri’s active ingredients (budesonide and formoterol fumarate) as separate inhalers. The other active ingredient, glycopyrrolate, is more difficult to get on its own.

Is Breztri the same as Symbicort?

No, Breztri isn’t the same as Symbicort. Symbicort is a dual-therapy inhaler that combines budesonide and formoterol. Breztri is a triple-therapy inhaler that combines budesonide, formoterol, and glycopyrrolate.