(SLB-050) Costs and Coverage of Metered-Dose Inhalers and Sustainable Alternatives Among Older Adults in the United States

Background: Several European countries have shifted from MDIs to equally effective, safer, and more sustainable DPIs and SMIs, cutting MDI use to 10–30% of all inhalers. In contrast, market sales data and our study of 9 million older Medicare beneficiaries (2008 to 2020) showed MDIs making up over 50% of all inhalers with no decreasing utilization trend. However, potential barriers, including insurance coverage and costs of inhalers, are still unknown.

Objectives: To examine the inhaler costs and insurance plan coverage of inhalers in U.S. Medicare older adult.

Methods: We used 100% fee-for-service Medicare data with Part D (2008–2022) to identify inhaler costs covered by the Part D plan and out-of-pocket (OOP) costs incurred by beneficiaries. Costs for each inhaler dispensing were categorized by inhaler device types (i.e., MDIs, DPIs, SMIs) and drug classes (inhaled corticosteroids [ICS] and long-/short-acting beta-agonists [L/SABA] and combination inhalers). Using the COVERAGE Search database, we extracted formulary data from all Part D plans in 10 large geographically representative states and described coverage status, tier placement, and requirements for prior authorization (PA) or step therapy (ST). We calculated mean costs for each device type and drug class. Insurance coverage was assessed by evaluating the percentage of plans covering each formulation by tier and PA/ST requirements.

Results: Of 160,845,280 inhalers dispensed to 10,494,068 older adults (mean age 74; 38% male; 85% White), mean OOP costs across all years for SABA MDIs ranged from $7–26 vs. $24–32 for DPIs/SMIs and $18–92 for ICS MDIs vs. $30–114 for DPIs/SMIs. For combination inhalers, OOP costs ranged from $24–114 for ICS/LABA MDIs vs. $25–98 for DPIs/SMIs and from $81–106 for ICS/LAMA/LABA MDIs vs. $36–100 for DPIs/SMIs. Similarly, plan-covered costs across all years showed that MDIs were less expensive than DPIs/SMIs for both SABA and ICS. For combination inhalers, DPIs/SMIs were less expensive than MDIs.
Among the 2530 Part D plans in 10 states,18% and 50% of the plans covered DPI formulations for SABA and ICS, respectively. When covered, 82% of SABA DPIs (367/448 plans) were assigned to higher formulary tiers (3 or 4), with 58% (257/448 plans) requiring PA/ST. Similarly, 76% of ICS DPIs (969/1276 plans) were assigned to higher formulary tiers (3 or 4), with 31.4% (399/1276) requiring PA/ST.

Conclusions: Most insurance plans excluded DPIs for SABA/ICS. When covered, they were placed in higher cost tiers. Consequently, utilization was very low, and OOP costs for DPIs for SABA and ICS were up to 3 times higher than MDIs. Ensuring affordable access to DPI/SMIs requires federal price caps, subsidies, comprehensive insurance coverage, and educational initiatives, as seen in European countries.