Old Medicine, Expensive Device: What Inhalers Cost Seniors Coping with COPD (Part 2 of 2)

By ALDP Co-founders Michael Glassner and Jason Young

Sept. 15, 2026 – In our last post, we wrote about children, asthma and the surprisingly high price of medicines delivered through inhalers.

In this post, we turn to older Americans living with chronic obstructive pulmonary disease. COPD is most often caused by smoking but can also result from long-term exposure to fumes, dust, chemicals and other lung irritants.

About 16 million Americans have been diagnosed with COPD. The disease damages the lungs over time and makes breathing harder. A serious flare-up can lead to hospitalization, and some patients never fully regain the lung function they had before it.

For someone already living with limited breath, an unaffordable inhaler or missed refill is not a small disruption.

So the pricing questions are worth asking again: Why can inhaled medicines remain so expensive? And what can policymakers do about it?

Old medicine, new device patents – again

Inhalers are both medicine and device. That distinction matters because patents can cover not only the drugs inside, but the inhaler that delivers them.

Consider Trelegy Ellipta, one of Medicare’s highest-spending respiratory drugs. It puts three medicines into a once-a-day inhaler. Trelegy itself dates to 2017, but its component medicines were already being used in FDA-approved inhalers before then, and the kinds of medicines they represent have been used to treat lung disease for decades. FDA has not approved a generic version.

But in 2024, the Federal Trade Commission challenged two patents GSK had listed for Trelegy in the FDA’s Orange Book. Both covered parts of the inhaler itself rather than Trelegy’s active medicines.

Why does that matter?

The Orange Book is the government’s official list of patents tied to approved drugs. If a generic manufacturer challenges a patent listed there and the brand company sues, FDA approval of the generic can be delayed for as long as 30 months.

The FTC’s argument was not that GSK had no right to patent its inhaler. It was that these patents covered the device rather than the medicines inside, and therefore should not receive the Orange Book’s additional power to delay generic competition.

GSK ultimately asked FDA to remove the challenged Trelegy patents from the Orange Book. Scrutiny produced movement without Congress first passing a new law.

And the distinction remains important. A better inhaler can be a real innovation. Innovation deserves patent protection and a fair return. But a patent on the device should not get an extra barrier against generic competition unless the law actually gives it one.

What seniors actually pay

Trelegy’s current list price is $697.73 for a month’s supply.

In 2024, about 1.27 million Medicare Part D beneficiaries used Trelegy, generating roughly $5.3 billion in gross Medicare spending.

What an individual senior pays at the pharmacy varies by plan. Medicare drug plans have different preferred drugs, copays and coverage rules.

Patients do have much better protection from high prescription bills today. In 2026, annual out-of-pocket spending on covered Part D drugs is capped at $2,100, which matters enormously. But it is protection from a high price, not a reduction in the price itself.

And there is a catch that matters especially for the readers of this post.

In 2024, after congressional scrutiny of high inhaler prices, Boehringer Ingelheim, AstraZeneca and GSK announced voluntary programs lowering many eligible patients’ inhaler costs to $35 a month. That was a real response to public pressure, and it reached a lot of people.

But it did not reach most seniors. Federal anti-kickback law generally bars manufacturers from offering copay assistance to patients enrolled in Medicare and other federal health programs. So a 71-year-old grandmother with COPD can read that the company making her inhaler has capped the cost at $35, and then learn the cap was never available to her.

The pattern still holds: public officials asked hard questions, companies faced public scrutiny, and corporate behavior changed. But what changed was assistance for commercially insured patients, such as people who are insured through their job. The list price did not move.

Where the burden actually falls

COPD is not evenly distributed across the country.

Among older Americans, new federal data found COPD was about 65 percent more common in nonmetropolitan areas than in large cities. That makes COPD an acute concern in rural America.

And the long-term trend is moving the wrong way. Over the past 25 years, COPD death rates fell in metropolitan America but rose significantly outside it.

Those are often the same communities where health care choices are already thinner: fewer specialists, longer drives for care, fewer pulmonary rehabilitation programs and, in too many places, fewer pharmacies.

Price is not the only challenge facing an older American with COPD in rural America. But it is one policymakers can do something about.

Then Medicare negotiated the price

For Trelegy, something important is about to change.

Starting Jan. 1, 2027, Medicare’s negotiated price for a 30-day supply of Trelegy will be $175. Its current list price is just under $700. That is a 75 percent difference.

One caveat is important. Medicare was not necessarily paying the full list price before negotiation. Drug plans and manufacturers negotiate rebates and discounts that bring the actual cost down.

But beginning next year, $175 becomes a real, public American price benchmark for Trelegy.

And we would point out something else. GSK negotiated that price with Medicare and continues to sell Trelegy.

The first Medicare negotiated prices took effect this year. So far, the warnings that negotiation would cause selected medicines to disappear from the market have not materialized.

Can the new price simply be avoided?

There is a reason to ask that question. In Part 1, we wrote about Flovent, a familiar children’s asthma medicine. After a change in Medicaid rebate rules made the brand more costly for GSK, the company withdrew Flovent and sold the same medicine as an authorized generic under a different label. The result included disrupted access for children.

But that story eventually moved, too. After sustained pressure from Senator Maggie Hassan, including an investigation into the withdrawal and barriers to generic competition, GSK agreed to allow a lower-cost generic competitor onto the market.

Again, scrutiny produced change.

The Flovent experience also makes us wary of any pricing policy with an easy exit. Fortunately, Medicare anticipated much of this problem. Its rules generally prevent a manufacturer from escaping a negotiated price simply by changing the strength or formulation of the same selected drug. An authorized generic made by the same company generally stays within the negotiated-price rules as well.

That is good policy.

It does not mean manufacturers will never have an incentive to move patients toward newer products carrying new prices. And a genuinely better medicine or device should be judged on its merits.

But policymakers should watch carefully when patients are moved from an older, lower-priced product to a higher-priced successor. A new device should not become an easy way around a price that has already been negotiated.

What actually changes the price

Older Americans living with COPD face problems beyond prescription drug prices. Rural communities need better access to specialists and pulmonary rehabilitation. And patients should not be casually switched from an inhaler they know how to use to one they do not. These are all crucial issues.

But our focus is drug prices. And across these two posts, four approaches stand out:

1. Competition. Keep improperly listed device patents from delaying legitimate generic competition. Patents should reward genuine innovation, not create an extra barrier to competition they were never entitled to have.
2. Fair Price. Medicare has established a negotiated price of $175 for Trelegy beginning in 2027. States buying prescription coverage for their own workers and retirees should use Medicare’s negotiated prices as benchmarks – and ask why they should pay more for the same medicine.
3. Accountability. Keep the rules that prevent manufacturers from escaping a negotiated price through modest changes to the same product, and watch closely when patients are moved to higher-priced successor products.
4. Scrutiny. Use the tools policymakers already have. Letters, hearings, investigations, testimony and public disclosure have repeatedly moved this inhaler market. They are not substitutes for lasting reform, but they can produce results while lawmakers build it.

Think about what happened across these two posts.

Public scrutiny helped produce $35 inhaler programs. GSK asked FDA to remove challenged Trelegy device patents. And sustained oversight helped clear the way for a lower-cost Flovent generic.

Different problems, different policymakers, and different tools. But each time, asking hard questions in public mattered.

One last question

Starting in January, Trelegy will carry a $175 Medicare negotiated price for a 30-day supply.

A 65-year-old with COPD enrolled in Medicare Part D can benefit from that benchmark.

A 64-year-old with the same disease, taking the same medicine in the same device, may be covered through an employer or state health plan paying considerably more.

Same medicine. Same device. Same country. One birthday apart.

That does not mean every health plan needs to become Medicare.

It does mean Medicare has established a real American price benchmark for Trelegy. States buying prescription drugs for their own workers and retirees should be asking a very simple question:

Why are we paying more?

We would welcome your thoughts.