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Ensuring Safe Transitions of Care in Patients with
Chronic Obstructive Pulmonary Disease

Medication Access and Cost Considerations

Determining access and affordability of a patients medication regimen is a key item to discuss with patients. The table and interactive flow chart included below offer some guidance.

Discussion/Counseling Points Related Resources

Medication Insurance/coverage types to consider:

  • Commercial insurance: determine tier coverage, may use manufacturer co-pay assistance cards
  • Medicare drug coverage (Part C & D): determine tier coverage, considerations to cover gap (“Donut Hole”) with Medigap
  • Medicare Part B coverage (Medically necessary services and Preventive services): covers nebulizer and nebulized medications at 80%. If patients have a supplement it covers the remaining 20% of cost. This requires an order with diagnosis code. Durable Medical Equipment companies are able to process claims for home delivery.
  • No insurance: consider coupons, discount groups, patient assistance programs, bulk replenishment programs, drug repository.

Consider Cost

Does patient have commercial insurance?
Yes
No
What is their Tier Copay?
  • Tier 1: Generic inhalers: Albuterol HFA.
  • Tier 2 or 3: Most inhalers are brand name only and require higher copays.
  • Prior Authorization: Non formulary
  • Not covered
  • Can review with “Coverage” app
  • Co-Pay Manufacturer Assistance Cards
Does the patient have Medicare Part C or D?
Yes
No
What is their Tier Copay?
  • Tier 1: Generic inhalers: Albuterol HFA.
  • Tier 2 or 3: Most inhalers are brand name only and require higher copays.
  • Prior Authorization: Non formulary
  • Not covered
  • If nebulized medications are required, may go through Medicare part B with or without supplement
  • Coverage gap (“Donut hole”)
Does the patient have Medicare Part B?
Yes
No
Does patient have a supplement?
Yes
No

Consider nebulized medications through Medicare Part B (80%) with supplement (20%) through a DME company that can process claims with supplement (usually mailed to patient’s home).

Does not apply toward patient’s “Donut Hole” medications.

Consider Albuterol and/or Ipratropium nebulized medication

Resources for Patients:
  • GoodRx.com
  • Rx Outreach.org
  • RxAssist.org
  • NeedyMed.org
  • Manufacturer websites
Or consider:
  • Albuterol and/or Ipratropium nebulized medication
  • Albuterol HFA
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