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A study of 31,219 commercial insurance plans found that lower-emission dry powder and soft mist inhalers were less often covered, and less often placed on preferred tiers without added restrictions, than metered-dose inhalers. The researchers say formulary changes could improve access while preserving metered-dose options when clinically appropriate.
Commercial insurance formularies cover lower-emission inhalers for asthma and chronic obstructive pulmonary disease (COPD) less often, and with more restrictions, than higher-emission metered-dose inhalers, a study of 31,219 plans found. The Rutgers-led research, published in JAMA Network Open, points to coverage design as a potential barrier to reducing inhaler-related greenhouse gas emissions while maintaining access to treatment.
The researchers examined coverage across commercial plan formularies in the 50 states and Washington, D.C., using data from May 2026. They compared metered-dose inhalers, which use hydrofluoroalkane propellants, with dry powder and soft mist inhalers, which do not use those propellants. The analysis covered short-acting beta-2 agonists (SABAs), inhaled corticosteroids (ICS), and combinations of ICS with long-acting beta-2 agonists (LABAs).
For SABAs, 66.4% of plans covered only a metered-dose inhaler and no propellant-free option. More than 99% of plans covered at least one ICS inhaler and at least one ICS-LABA combination, but propellant-free versions were covered by 89.5% and 82.6% of plans, respectively.
Coverage on a preferred tier without prior authorization or step therapy was also less common for propellant-free devices. The rates were 7.8% for SABAs, 61.8% for ICS inhalers, and 52.2% for ICS-LABA combinations. For metered-dose inhalers in those classes, the corresponding rates were 99.2%, 93.8%, and 88.7%. Prior authorization and step therapy can require additional approval or treatment steps before a plan covers a medicine.
How Formularies Shape Inhaler Access
Formulary placement can affect which devices patients can obtain through their insurance and how much work is needed to secure coverage. The study authors said clinicians may select a lower-emission inhaler suited to a patient only to find that the plan excludes it or requires extra steps. That can make the coverage decision relevant to both patient access and efforts to reduce emissions.
The findings describe plan-level coverage, not what individual patients paid or which inhalers they ultimately used. Still, the gap in preferred-tier placement suggests that adding a propellant-free option to a plan’s covered list may not, by itself, make it as easy to obtain as a metered-dose inhaler.
The authors recommended that payers place at least one propellant-free option in each medication class on preferred tiers, reduce utilization-management requirements for those options, and make coverage rules more transparent. They also said metered-dose inhalers should remain available when clinically indicated. Those proposals are recommendations from the researchers; the study did not test whether the changes would alter prescribing or emissions.
Earlier Findings and VA Experience
The researchers said a prior study found similar coverage patterns in Medicare plans for the three inhaler classes. They noted that the classes together account for nearly all inhaler-related greenhouse gas emissions in the United States, which they compared with the annual emissions of about half a million gasoline-powered passenger vehicles. That is an estimate of emissions, not a count of vehicles replaced or journeys avoided.
The report also points to the Veterans Health Administration as an example of a system-wide formulary change. VA inhaler-related emissions fell 68% from 2008 to 2023 on an annual basis, according to the cited research. A cost-motivated 2021 formulary renegotiation made a fluticasone-salmeterol dry powder inhaler the preferred ICS-LABA option in place of a budesonide-formoterol metered-dose inhaler.
A previous VA study found a small increase in emergency and hospital care after that dry powder inhaler switch. The Rutgers researchers cited European guidance that promotes patient review and shared decision-making on lower-emission inhalers rather than blanket substitution. These examples point to the need to weigh device access and clinical suitability alongside emissions and cost.
““Meaningful reductions in inhaler-related emissions in the U.S. will require lower formulary barriers for propellant-free options while preserving [metered-dose inhaler] access when clinically indicated.””
— Soko Setoguchi and colleagues
What the Plan Data Cannot Show
The study measured plan-level formulary coverage, not enrollment-weighted access for individual patients. It did not assess actual out-of-pocket costs, exceptions to coverage, prescribing or dispensing patterns, or whether switching devices would be clinically suitable for particular patients. The researchers also said the source data did not let them distinguish some generic products.
The findings therefore show how plans list and restrict inhalers, but do not establish how often patients encounter those restrictions, whether they switch devices, or how much emissions would change if coverage rules changed. The available material does not specify whether insurers have adopted the researchers’ proposals or how any future changes would affect patient outcomes.
Potential Changes to Coverage Rules
The study authors called on insurers to make at least one propellant-free inhaler in each class a preferred option, reduce prior authorization and step-therapy hurdles for those choices, and publish clearer coverage information. Any changes would need to preserve access to metered-dose inhalers when a clinician determines they are appropriate.
The next evidence needed includes whether changes to formularies alter what clinicians prescribe, what patients can obtain, and inhaler-related emissions. The study does not report a policy timetable or announced insurer changes, so it remains unclear when, or whether, payers will act on the recommendations.
Key Questions
What did the study find about insurance coverage?
In a review of 31,219 commercial plans, lower-emission dry powder and soft mist inhalers were generally covered less often or placed on preferred tiers less often without prior authorization or step therapy than metered-dose inhalers.
Which inhalers were compared?
The researchers compared metered-dose inhalers, which use hydrofluoroalkane propellants, with propellant-free dry powder and soft mist devices across SABA, ICS, and ICS-LABA medication classes used for asthma and COPD.
Does the study show patients are switching inhalers?
No. The analysis assessed plan formularies. It did not measure prescribing, dispensing, patient switching, individual costs, or whether a device change is suitable for a particular patient.
What changes did the researchers recommend?
They recommended that insurers place at least one propellant-free option in each class on a preferred tier, reduce utilization-management requirements for those options, and make coverage rules clearer while preserving metered-dose inhaler access when clinically indicated.
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