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A study of commercial insurance formularies found that lower-emission dry powder and soft mist inhalers were less often covered, and less often covered on preferred terms, than metered-dose inhalers. The researchers say insurers could reduce access barriers while retaining metered-dose options when clinically appropriate.
A study of 31,219 commercial insurance plans found that lower-emission inhalers for asthma and chronic obstructive pulmonary disease were less often covered, and less often available on preferred terms, than metered-dose inhalers that use hydrofluoroalkane propellants. The findings point to insurance formularies as a potential barrier to patients and clinicians choosing propellant-free devices, according to researchers reporting in JAMA Network Open.
The analysis examined coverage for three medication categories: short-acting beta-2 agonists, inhaled corticosteroids, and inhaled corticosteroid–long-acting beta-2 agonist combinations. For short-acting beta-2 agonists, 66.4% of plans covered only a metered-dose inhaler, with no propellant-free option covered. More than 99% of plans covered at least one inhaled corticosteroid and one combination inhaler, 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 also differed by device type. Among metered-dose inhalers, the shares meeting those conditions were 99.2% for short-acting beta-2 agonists, 93.8% for inhaled corticosteroids, and 88.7% for combination inhalers. For propellant-free versions, the corresponding shares were 7.8%, 61.8%, and 52.2%. These figures describe plan formularies, not the coverage or costs experienced by each person enrolled in them.
The researchers identified dry powder inhalers and soft mist inhalers as lower-emission alternatives because they do not use hydrofluoroalkane propellants. They proposed that insurers place at least one propellant-free option in each medication class on a preferred tier, reduce utilization-management requirements for those products, and make coverage terms more transparent. They also said access to metered-dose inhalers should be preserved when clinically indicated.
How Coverage Shapes Inhaler Choices
Formulary rules can affect which devices a patient can obtain and how much effort is required to get them. The researchers said a clinician may identify a suitable lower-emission inhaler only to find it is not covered or requires extra approval steps. The study did not measure how often that situation occurs in practice, but its plan-level findings show that preferred coverage was substantially less common for propellant-free options in all three medication categories.
The issue also has an environmental dimension. Metered-dose inhalers use hydrofluoroalkane propellants that contribute to greenhouse gas emissions. A previous study cited by the researchers estimated that emissions from the three medication classes examined together are equivalent to those from about half a million gasoline-powered passenger vehicles driven for one year. That estimate provides scale for the emissions at issue; it does not show how much emissions would fall under any particular insurance change.
Device choice also has clinical implications. A previous study of a Veterans Health Administration formulary change found a small increase in emergency and hospital care after a switch to dry powder inhalers. The finding supports careful, evidence-based implementation and patient review; it does not establish that every patient would experience harm from switching devices.
Coverage Across Three Inhaler Classes
The research team, led by Soko Setoguchi of the Rutgers RWJBarnabas Center for Climate, Health, and Healthcare, used MMIT Coverage Search to examine commercial formularies across the 50 states and Washington, D.C. The data were collected in May 2026. The analysis compared coverage of metered-dose inhalers with lower-emission dry powder and soft mist options in commonly used medication classes for asthma and COPD.
The authors said their earlier research found similar coverage patterns in Medicare plans. They described the commercial insurance results as distinctive because private plans generally offered better coverage than Medicare while still showing numerous barriers for lower-emission devices. Separately, the Veterans Health Administration recorded a 68% reduction in annual inhaler-related emissions from 2008 to 2023. Researchers attributed part of that decrease to a 2021, cost-motivated formulary renegotiation that made a dry powder combination inhaler preferred over a metered-dose alternative.
The authors also pointed to European prescribing guidance that promotes lower-emission devices through patient review and shared decision-making. They said metered-dose inhalers account for fewer than half of inhalers overall in Europe. These examples offer context for possible policy approaches, but the commercial-plan study did not compare clinical outcomes across countries or assess the effects of adopting those policies in the United States.
““It is not the availability.””
— Soko Setoguchi and Ashwaghosha Parthasarathi, study authors, in an email
Limits of the Formulary Data
The analysis measured plan-level coverage, not individual enrollment or what patients paid out of pocket. It did not assess coverage exceptions, prescribing or dispensing patterns, or whether switching devices would be clinically appropriate for particular patients. The researchers also said the data source did not allow them to distinguish some generic products.
As a result, the study does not establish how many patients encountered a denial or delay, how often they used a covered alternative, or what effect formulary changes would have on emissions or health outcomes. It also does not determine whether a lower-emission device is suitable for every person with asthma or COPD. Those questions remain open alongside the practical effects of any proposed coverage changes.
Potential Changes to Preferred Coverage
The researchers called on U.S. payers to place at least one propellant-free option per medication class on a preferred tier, minimize prior authorization and step therapy for those options, and provide clearer information to employers and purchasers. Their proposal would leave metered-dose inhalers available when clinically appropriate.
The study does not report that insurers have adopted these recommendations or set a timetable for changes. Any move toward lower-emission devices would require decisions by payers and review of patient needs. Further evidence about actual access, costs, prescribing, and outcomes could help show how formulary changes affect patients and emissions.
Key Questions
What did the study find about commercial insurance coverage?
In the plans examined, lower-emission inhalers were less often covered and less often covered on preferred terms than metered-dose inhalers. The size of the gap varied across the three medication classes.
Which inhalers were described as lower-emission?
The study compared metered-dose inhalers, which use hydrofluoroalkane propellants, with dry powder and soft mist inhalers, which do not use those propellants.
Does the analysis show what patients paid?
No. It examined plan formularies and did not assess individual out-of-pocket costs, coverage exceptions, or whether a person was enrolled in a particular plan.
Are researchers recommending that everyone switch inhalers?
No. They recommended lowering coverage barriers for propellant-free options while preserving metered-dose inhalers when clinically indicated. Device suitability and the effects of switching for individual patients were outside the study’s assessment.
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