In 2013, the New York Times published an expose on the high price of asthma inhalers, in an article headlined “The Soaring Cost of a Simple Breath.”
So what’s happened in the 5 years since? Prices have only gotten worse.
A GoodRx analysis of cash prices for asthma inhalers shows that prices have climbed about 35% since 2013, from an average price of around $280 in 2013 to more than $380 today.
The average cash price for one inhaler of Advair, a leading medication for asthma, increased from $316 in 2013 to $496 in 2018 – a 56% increase. The average cash price for Flovent, another widely prescribed brand, increased 41% between 2013 and 2018, from $207 to $292.
By comparison, had prices increased in step with the inflation rate, that $280 average price in 2013 would be just $299 today, only a 7% increase.
The average inhaler price combines prices for 16 leading inhaler products. These numbers are based on a representative sample of prescription fills at US pharmacies. They reflect overall US prescriptions, not fills using GoodRx. The data comes from several sources including pharmacies and insurers and provides a representative sample of nationwide US prescription drug volume.
This data represents the full list prices at the pharmacy – the so-called “usual and customary” price; it doesn’t include insurance co-payments or co-insurance payments. Even though most Americans pay for these drugs with insurance, more people every year are paying some or all of the cash prices out of pocket, due to health insurance with high deductibles, insurance formulary changes that push some drugs off the list of covered medications, and fewer annual enrollments into Obamacare.
Asthma is an especially expensive condition for many Americans. The annual per-person medical cost of asthma was $3,266 in 2013, according to a recent report in Annals of American Thoracic Society. Of that, $1,830 was for prescriptions. Though people with insurance may be protected from the full brunt of these costs, many popular inhalers are often placed on lower tiers of coverage, meaning that patients face higher copays or find their preferred medication excluded altogether.
Even worse, high costs for asthma disproportionately hit underinsured and uninsured individuals. A report done by the CDC found that in some states as many as 20% of people with asthma do not have insurance, and are forced to pay out of pocket for their inhalers. Even more, individuals lacking insurance tend to live in lower-income areas, which tend to have higher rates of asthma.
Overall, about 15.4 million people in the U.S. had treated asthma each year – about 8.6% of the population, up from about 3% in 1980. The total annual cost of asthma in the U.S., including medical care, absenteeism and mortality, is estimated at $81.9 billion.
How environmental concerns made inhalers more expensive
Up until 2005, available inhalers contained chlorofluorocarbons (CFC), a greenhouse gas that is known to destroy the ozone layer. They were affordable and effective. At the time most products that contained chlorofluorocarbons, like packing materials and refrigerants, were banned per an agreement intended to protect the ozone layer called the Montreal Protocol. Unter this agreement, inhalers were considered essential medications and were exempt.
But this exemption was overturned in 2005 with some help from pharmaceutical lobbyists. From 2005 to 2010, Pharmaceutical manufacturers paid lobbyists over $500,000 to work to ban old CFC inhalers, with the argument of environmental protection. But, why would manufacturers spend money to ban CFC inhalers, ultimately deeming their products illegal and unsellable?
Think of it this way, in order to remove the CFC from an inhaler, manufacturers only have to substitute the propellant used, without touching the active ingredients. This means that manufacturers could rebrand their product, with little to no drug research and development costs, and add a completely new patent protection to their product that could grant them market exclusivity. And this is just what they did.
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Starting in 2008, CFC containing inhalers were swapped out with a new kind of inhaler – the HFA inhalers that we see on the market today. Herein lies the problem. Upon releasing the new HFA inhalers, manufacturers were able to slap multiple new patents on their new inhalers. These patents granted manufacturers market exclusivity on their product, and prevented affordable generic alternatives from being manufactured. These patents also created a lack of competition in the inhaler space which allowed for large price increases. This CFC ban also eliminated Primatene Mist inhalers, an affordable over-the-counter spray that was effective for those who couldn’t afford prescription inhalers.
So has this ban actually caused an increase in inhaler prices? Yes. Since the 1990s, out of pocket costs increased by 50% for patients with private insurance. What’s more, even after the CFC ban in 2008, average cash prices for popular inhalers also increased. As the new GoodRx analysis shows, those price increases haven’t shown any sign of slowing down even several years after the new HFA medications arrived.
While the switch from CFC to HFA inhalers was positive for pharmaceutical companies, it hasn’t had that large of an impact on the environment. The ban on CFC inhalers has been estimated to prevent only 4,500 tons of greenhouse gas emissions a year, which is only about 0.5% of annual greenhouse gas production.
Good news – generic versions are available
Thankfully, several generic versions of the new inhalers and nebulizers began to reach the market in 2015 and 2016. Currently, Xopenex HFA (levalbuterol), Airduo (fluticasone/salmeterol), and Pulmicort (budesonide) all have approved generics. Cash prices for levalbuterol and fluticasone/salmeterol are under $100 (their brands cost around $80 and $300 respectively), but budesonide is more expensive with cash prices averaging around $176.24 (the brand costs around $250).
More generic inhalers are in the pipeline. A generic version of Advair, a leading inhaler, has long been expected from Sandoz, but it may take longer than expected. The FDA was expected to approve Advair’s generic in 2018, but this past February, the FDA declined the Sandoz application. This doesn’t mean that generic Advair is out of the question, but it could be until 2020 to see one. Read here for more on Advair’s generic, and tips on how to save.
So how can I save on inhalers?
- Talk to your doctor about an inhaler that has a generic. In recent years, as patents have worn off, more and more inhalers have gone generic. Fluticasone/salmeterol (AirDuo), and albuterol are two of the more popular inhalers that have gone generic recently. Another popular inhaler, Advair, is set to go generic soon (we hope). More on that here.
- Use a manufacturer coupon or patient assistance programs. Some manufacturers offer programs that can help you afford your prescription. Call your inhaler’s manufacturer to see if there are any programs you qualify for.
- If you have insurance, make sure your brand is on your formulary. The majority of plans do offer preferred coverage for some inhalers, but if for some reason your plan doesn’t cover your preferred inhaler, talk to your doctor about submitting an appeal.
- Use a GoodRx coupon. GoodRx offers discounts for all FDA approved inhalers online. A discount can save you up to 80% on your out of pocket cost. Every little bit helps!
- Try to appeal your coverage. If you have insurance and your plan doesn’t cover Symbicort, ask your doctor about submitting an appeal, Some plans require prior authorizations—meaning you need permission from your insurance plan and a special request from your doctor before you can fill your prescription. If you have insurance, call your provider and ask how to get this process started.