Out of breath

Price is only one part of access. For chronic conditions like asthma, a “generic” label does not automatically mean a lower out-of-pocket bill. Insurance design, pharmacy contracting and formulary placement can all decide whether a patient actually receives a medicine they can afford to keep taking.

Switches can create a practical burden even when the medicine is familiar. Inhalers are not interchangeable in the real world if the device, dose counter or inhalation steps change. A patient who has learned one routine may struggle with another, which can affect confidence, adherence and day-to-day symptom control. That makes continuity of device and instructions an important part of care, not an afterthought.

The timing of a disruption matters. During months when flu, Covid, RSV and cold air are more likely to aggravate airways, any interruption in controller therapy can become more consequential. The central risk is not just that a prescription changes, but that a patient delays refills, stretches doses or stops treatment altogether because the new option is confusing or unaffordable.

What’s uncertain is how widely these problems will spread. Some patients may move to the new version without difficulty; others may need a formulary exception or a different inhaler entirely. The broader lesson is that medication policy should be judged by what happens at the pharmacy counter, not only by the drug name on paper.

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For asthma patients, a scramble

After a popular asthma inhaler was recently taken off the market, Charita Boseman started looking for alternatives for her 4-year-old daughter. The process, she says, left her “literally in tears.”

Since September 2022, she had used Flovent to control her daughter’s asthma. With her insurance, Boseman paid just $10 a month. But as of Jan. 1, the drug manufacturer GSK has discontinued Flovent in the US and replaced it with a generic version. For some patients, this comes at a steep cost: Boseman found out she’d pay $70 a month out of pocket for the generic because her insurance won’t cover as much. That’s more than she can afford.

So Boseman, who is 44 and lives in Cleveland Heights, Ohio, has been on the phone with insurance companies, pharmacies and her pediatrician’s office urgently seeking other options.

“I’m livid,” Boseman says. “I can’t believe this is happening right now.”

The timing isn’t ideal either. All this is unfolding right as respiratory illnesses that can trigger asthma, like flu, Covid and RSV, are on the rise. Cold weather can also make asthma symptoms worse.

Boseman isn’t alone in her struggles. Many asthma patients are scrambling in the new year to find a substitute for the popular inhaler. Sold as either an aerosol or a powder, Flovent has helped many people prevent asthma symptoms by reducing inflammation in the airways of the lungs. In 2022 alone, Medicaid patients filled 2.5 million prescriptions for it.

In theory, the price of a generic should be lower for patients, says Kenneth Mendez, chief executive officer of the Asthma and Allergy Foundation of America. The issue is whether or not it’s covered by insurance. In the case of the generic, some big insurers appear to not be paying as much for it.

A mother in Houston tells me that she recently paid $180 for a month’s supply of the generic for her 8-year-old daughter whose cough had persisted for over a month.

“I wasn’t going to not pay for it,” she says. “My kid needs it. You don’t have a choice.”

A GSK spokesperson says the company made a “business decision” to launch a generic Flovent “as to way to help ensure patients continue to have access to these important medicines, potentially at a lower cost.”

But the move could help the company financially. Under a provision of a law that takes effect this year, companies may have to pay more rebates to Medicaid for increasing the price of drugs more than inflation. Flovent’s price has risen about 50% over the past decade, according to GoodRx. By replacing Flovent with a generic version, GSK could avoid paying the Medicaid penalties.

A spokesman for CVS Health Corp., one of the largest drug-benefits managers, said it decided to cover a different brand-name inhaler called Pulmicort, which was less expensive than the generic Flovent.

Boseman says her daughter recently tried Pulmicort, but got frustrated because it’s more complicated to use than Flovent.

“She said, ‘Mommy, I can’t do that,’” she says.

For asthma patients, it’s important to stay on the medication prescribed by their doctor, Mendez says, because they may need to take daily maintenance doses to reduce airway inflammation. If they were prescribed Flovent, they should try to get the authorized generic version because it’s the same formulation and delivery system, he adds. If that’s not covered by their insurance, they should ask their doctor if there’s an affordable substitute. They can also seek to get their insurance company to cover the generic version through what’s called a formulary exception.

The potential disruption could have both financial and health consequences for patients suffering from a condition that on average leads to 10 deaths each day in the US. “If patients stop their medication because they can’t afford it, then they could end up suffering from an asthma attack,” Mendez says. “This could lead to hospitalization, missed time from work, or even death.” — Gerry Smith

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