Pro Comfort Spacer With Mask

Generic: ,assist

Device

DEVICES

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Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Source: PDF  ·  Formulary date: Oct 15, 2026  ·  Checked: 4 hours, 29 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect Bronze 6500 Indiv Med Deductible
via Procare Spacer With Child Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD 2200 Indiv Med Deductible
via Procare Spacer With Child Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect myDiabetesCare Bronze
via BREATHERITE SPACER-LG CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver 3600 Indiv Med Deductible
via BREATHERITE SPACER-NEONATE MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver 3000 Indiv Med Deductible
via BREATHERITE SPACER-NEONATE MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze 5500 Indiv Med Deductible
via Procare Spacer With Child Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Gold 1500 Indiv Med Deductible
via Procare Spacer With Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver 3600 Indiv Med Deductible
via Procare Spacer With Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze RD 5000 Indiv Med Deductible
via Procare Spacer With Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect myDiabetesCare Bronze
via Procare Spacer With Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver 3000 Indiv Med Deductible
via Procare Spacer With Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD 3500 Indiv Med Deductible
via Procare Spacer With Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver 5000 Indiv Med Deductible
via Procare Spacer With Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze 7000 HSA Indiv Med Deductible
via Procare Spacer With Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze RD 5000 Indiv Med Deductible
via Procare Spacer With Child Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD 3500 Indiv Med Deductible
via Procare Spacer With Child Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect myDiabetesCare Silver
via Procare Spacer With Child Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver 5000 Indiv Med Deductible
via Procare Spacer With Child Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze 6500 Indiv Med Deductible
via Procare Spacer With Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD 2200 Indiv Med Deductible
via Procare Spacer With Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect myDiabetesCare Silver
via Procare Spacer With Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze 5500 Indiv Med Deductible
via Procare Spacer With Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze RD 6000 Indiv Med Deductible
via Procare Spacer With Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver 3600 Indiv Med Deductible
via Procare Spacer With Child Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD 5000 Indiv Med Deductible
via Procare Spacer With Child Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze 7000 HSA Indiv Med Deductible
via Procare Spacer With Child Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze RD 6000 Indiv Med Deductible
via Procare Spacer With Child Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Gold 1500 Indiv Med Deductible
via Procare Spacer With Child Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect myDiabetesCare Bronze
via Procare Spacer With Child Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver 3000 Indiv Med Deductible
via Procare Spacer With Child Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver 5000 Indiv Med Deductible
via Breatherite Spacer-Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect myDiabetesCare Silver
via Breatherite Spacer-Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD 5000 Indiv Med Deductible
via Breatherite Spacer-Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze 5500 Indiv Med Deductible
via Breatherite Spacer-Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze 7000 HSA Indiv Med Deductible
via Breatherite Spacer-Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze RD 6000 Indiv Med Deductible
via Breatherite Spacer-Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect myDiabetesCare Bronze
via Breatherite Spacer-Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD 3500 Indiv Med Deductible
via Breatherite Spacer-Infant Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze 6500 Indiv Med Deductible
via Breatherite Spacer-Infant Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD 2200 Indiv Med Deductible
via Breatherite Spacer-Infant Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver 5000 Indiv Med Deductible
via Breatherite Spacer-Infant Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect myDiabetesCare Silver
via Breatherite Spacer-Infant Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver 3600 Indiv Med Deductible
via Breatherite Spacer-Infant Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD 5000 Indiv Med Deductible
via Breatherite Spacer-Infant Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze 5500 Indiv Med Deductible
via Breatherite Spacer-Infant Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze 7000 HSA Indiv Med Deductible
via Breatherite Spacer-Infant Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze RD 6000 Indiv Med Deductible
via Breatherite Spacer-Infant Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Gold 1500 Indiv Med Deductible
via Breatherite Spacer-Infant Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect myDiabetesCare Bronze
via Breatherite Spacer-Infant Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver 3000 Indiv Med Deductible
via Breatherite Spacer-Infant Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD 3500 Indiv Med Deductible
via BREATHERITE SPACER-LG CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze 6500 Indiv Med Deductible
via BREATHERITE SPACER-LG CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD 2200 Indiv Med Deductible
via BREATHERITE SPACER-LG CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver 5000 Indiv Med Deductible
via BREATHERITE SPACER-LG CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze RD 5000 Indiv Med Deductible
via BREATHERITE SPACER-LG CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect myDiabetesCare Silver
via BREATHERITE SPACER-LG CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver 3600 Indiv Med Deductible
via BREATHERITE SPACER-LG CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD 5000 Indiv Med Deductible
via BREATHERITE SPACER-LG CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze 5500 Indiv Med Deductible
via BREATHERITE SPACER-LG CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze 7000 HSA Indiv Med Deductible
via BREATHERITE SPACER-LG CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze RD 6000 Indiv Med Deductible
via BREATHERITE SPACER-LG CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Gold 1500 Indiv Med Deductible
via BREATHERITE SPACER-LG CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver 3000 Indiv Med Deductible
via BREATHERITE SPACER-LG CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD 3500 Indiv Med Deductible
via BREATHERITE SPACER-NEONATE MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze 6500 Indiv Med Deductible
via BREATHERITE SPACER-NEONATE MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD 2200 Indiv Med Deductible
via BREATHERITE SPACER-NEONATE MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver 5000 Indiv Med Deductible
via BREATHERITE SPACER-NEONATE MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze RD 5000 Indiv Med Deductible
via BREATHERITE SPACER-NEONATE MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect myDiabetesCare Silver
via BREATHERITE SPACER-NEONATE MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD 5000 Indiv Med Deductible
via BREATHERITE SPACER-NEONATE MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze 5500 Indiv Med Deductible
via BREATHERITE SPACER-NEONATE MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze 7000 HSA Indiv Med Deductible
via BREATHERITE SPACER-NEONATE MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze RD 6000 Indiv Med Deductible
via BREATHERITE SPACER-NEONATE MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Gold 1500 Indiv Med Deductible
via BREATHERITE SPACER-NEONATE MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect myDiabetesCare Bronze
via BREATHERITE SPACER-NEONATE MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect myDiabetesCare Silver
via BREATHERITE SPACER-SM CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver 3600 Indiv Med Deductible
via BREATHERITE SPACER-SM CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD 5000 Indiv Med Deductible
via BREATHERITE SPACER-SM CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze 5500 Indiv Med Deductible
via BREATHERITE SPACER-SM CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze 7000 HSA Indiv Med Deductible
via BREATHERITE SPACER-SM CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze RD 6000 Indiv Med Deductible
via BREATHERITE SPACER-SM CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD 5000 Indiv Med Deductible
via Procare Spacer With Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze CMS Standard
via Breatherite Spacer-Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD CMS Standard
via Breatherite Spacer-Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze RD CMS Standard
via Breatherite Spacer-Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver CMS Standard
via Breatherite Spacer-Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Gold RD CMS Standard
via Breatherite Spacer-Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Gold CMS Standard
via Breatherite Spacer-Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze CMS Standard
via Breatherite Spacer-Infant Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD CMS Standard
via Breatherite Spacer-Infant Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze RD CMS Standard
via Breatherite Spacer-Infant Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver CMS Standard
via Breatherite Spacer-Infant Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Gold RD CMS Standard
via Breatherite Spacer-Infant Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Gold CMS Standard
via Breatherite Spacer-Infant Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze CMS Standard
via BREATHERITE SPACER-LG CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD CMS Standard
via BREATHERITE SPACER-LG CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze RD CMS Standard
via BREATHERITE SPACER-LG CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver CMS Standard
via BREATHERITE SPACER-LG CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Gold RD CMS Standard
via BREATHERITE SPACER-LG CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Gold CMS Standard
via BREATHERITE SPACER-LG CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze CMS Standard
via BREATHERITE SPACER-NEONATE MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD CMS Standard
via BREATHERITE SPACER-NEONATE MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze RD CMS Standard
via BREATHERITE SPACER-NEONATE MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver CMS Standard
via BREATHERITE SPACER-NEONATE MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Gold RD CMS Standard
via BREATHERITE SPACER-NEONATE MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Gold CMS Standard
via BREATHERITE SPACER-NEONATE MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze CMS Standard
via BREATHERITE SPACER-SM CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD CMS Standard
via BREATHERITE SPACER-SM CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze RD CMS Standard
via BREATHERITE SPACER-SM CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver CMS Standard
via BREATHERITE SPACER-SM CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Gold RD CMS Standard
via BREATHERITE SPACER-SM CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Gold CMS Standard
via BREATHERITE SPACER-SM CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze CMS Standard
via Procare Spacer With Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD CMS Standard
via Procare Spacer With Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze RD CMS Standard
via Procare Spacer With Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver CMS Standard
via Procare Spacer With Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Gold RD CMS Standard
via Procare Spacer With Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Gold CMS Standard
via Procare Spacer With Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze CMS Standard
via Procare Spacer With Child Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD CMS Standard
via Procare Spacer With Child Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze RD CMS Standard
via Procare Spacer With Child Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver CMS Standard
via Procare Spacer With Child Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Gold RD CMS Standard
via Procare Spacer With Child Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Gold CMS Standard
via Procare Spacer With Child Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze 6500 Indiv Med Deductible
via Breatherite Spacer-Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD 3500 Indiv Med Deductible
via Breatherite Spacer-Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD 2200 Indiv Med Deductible
via Breatherite Spacer-Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Gold 1500 Indiv Med Deductible
via Breatherite Spacer-Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver 3000 Indiv Med Deductible
via Breatherite Spacer-Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze RD 5000 Indiv Med Deductible
via Breatherite Spacer-Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver 3600 Indiv Med Deductible
via Breatherite Spacer-Adult Mask 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver 5000 Indiv Med Deductible
via BREATHERITE SPACER-SM CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect myDiabetesCare Bronze
via BREATHERITE SPACER-SM CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze 6500 Indiv Med Deductible
via BREATHERITE SPACER-SM CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD 3500 Indiv Med Deductible
via BREATHERITE SPACER-SM CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver RD 2200 Indiv Med Deductible
via BREATHERITE SPACER-SM CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Gold 1500 Indiv Med Deductible
via BREATHERITE SPACER-SM CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Silver 3000 Indiv Med Deductible
via BREATHERITE SPACER-SM CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze RD 5000 Indiv Med Deductible
via BREATHERITE SPACER-SM CHLD MSK 		Tier 3 - Preferred Brand — — ✓ QL
Connect Bronze RD 5000 Indiv Med Deductible
via Breatherite Spacer-Infant Mask 		Tier 3 - Preferred Brand — — ✓ QL
Source: Excel (XLSX)  ·  Formulary date: Sep 23, 2026  ·  Checked: 4 hours, 29 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026
via Breatherite Spacer-Adult Mask 		Tier 2 - Brand Formulary (Basic Core) — — — None
TRICARE Uniform Formulary 2026
via Breatherite Spacer-Infant Mask 		Tier 2 - Brand Formulary (Basic Core) — — — None
TRICARE Uniform Formulary 2026
via BREATHERITE SPACER-LG CHLD MSK 		Tier 2 - Brand Formulary (Basic Core) — — — None
TRICARE Uniform Formulary 2026
via BREATHERITE SPACER-NEONATE MSK 		Tier 2 - Brand Formulary (Basic Core) — — — None
TRICARE Uniform Formulary 2026
via BREATHERITE SPACER-SM CHLD MSK 		Tier 2 - Brand Formulary (Basic Core) — — — None
TRICARE Uniform Formulary 2026
via Clever Choice Holding Chamber 		Tier 2 - Brand Formulary (Basic Core) — — — None
TRICARE Uniform Formulary 2026 Tier 2 - Brand Formulary (Basic Core) — — — None
TRICARE Uniform Formulary 2026
via Procare Spacer With Adult Mask 		Tier 2 - Brand Formulary (Basic Core) — — — None
TRICARE Uniform Formulary 2026
via Procare Spacer With Child Mask 		Tier 2 - Brand Formulary (Basic Core) — — — None
TRICARE Uniform Formulary 2026
via Pure Comfort Spacer With Mask 		Tier 2 - Brand Formulary (Basic Core) — — — None
TRICARE Uniform Formulary 2026
via Space Chamber-large Mask 		Tier 2 - Brand Formulary (Basic Core) — — — None
TRICARE Uniform Formulary 2026
via Space Chamber-medium Mask 		Tier 2 - Brand Formulary (Basic Core) — — — None
TRICARE Uniform Formulary 2026
via Space Chamber-small Mask 		Tier 2 - Brand Formulary (Basic Core) — — — None
TRICARE Uniform Formulary 2026
via Vortex Vhc Frog Mask 		Tier 2 - Brand Formulary (Basic Core) — — — None
TRICARE Uniform Formulary 2026
via Vortex Vhc Ladybug Mask 		Tier 2 - Brand Formulary (Basic Core) — — — None
TRICARE Uniform Formulary 2026
via Vortex Vhc Pediatric Mask 		Tier 2 - Brand Formulary (Basic Core) — — — None
TRICARE Uniform Formulary 2026
via Aerochamber Z-stat Plus 		Tier 2 - Brand Formulary (Basic Core) — — — None
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