The discontinuation of a popular asthma inhaler this week has raised alarms among doctors who worry about patients, particularly kids, experiencing delays in accessing alternatives.

Why it matters: The potential gaps in access come at a peak time in respiratory virus season, when breathing conditions like asthma, commonly treated with the inhalers, are more likely to be exacerbated.

• The case of GlaxoSmithKline's discontinued inhaler also highlights health care's unusual economics and the challenges in curbing costs.

Catch up quick: GSK told the Food and Drug Administration last year it would stop making inhaled steroid medications Flovent HFA and Flovent Diskus as of Jan. 1. Patients would instead have access to an "authorized generic" version of these products, which started to hit the market in 2022.

• The drugs, which are being distributed by Prasco Laboratories, are identical aside from branding and come with a lower list price.
• But doctors tell Axios many pharmacy benefit managers and insurers that previously covered the branded versions are refusing to cover the generics. And in some cases, they stopped covering Flovent even before it was discontinued.
• That likely has to do with what many health policy experts say are warped incentives in the complex system for pricing drugs. Pharmacy benefit managers may prefer to cover higher-priced drugs because they can earn more by negotiating larger discounts, the Wall Street Journal points out.

Between the lines: GSK's decision to end the branded version of Flovent is tied to a new change in federal law aimed at constraining drug price increases, per the WSJ.

• Starting Jan. 1, a cap was lifted on how much manufacturers would have to rebate Medicaid if their prices rose faster than inflation. The change meant that drugmakers would essentially have to pay Medicaid for providing certain drugs that had large price increases.
• GoodRx data shows Flovent's list price has jumped 47% since 2014, CNN reported.
• "These are precisely the sort of drugs that will be affected by the new policy eliminating the Medicaid rebate cap," William Feldman, an associate physician at Brigham and Women's Hospital, told CNN.

Zoom in: Pediatricians, in particular, are frustrated that their patients might not have an age-appropriate alternative if the generic isn't covered.

• Flovent had been preferred by many pediatricians because the inhaler made it possible to use the drug in the youngest children, Erin Syverson, an attending physician at Boston Children's Hospital, told Axios.
• "It actually affects the health care system by creating increased costs, right? These kids end up in the emergency department," said Shilpa Patel, medical director of the IMPACT DC Asthma Clinic and an emergency physician at Children's National Hospital.
• Patel said she's already seen patients in the emergency room who were no longer able to access Flovent.
• "I see them in the ER, and you ask them, 'Oh, why did you stop the Flovent?'" Patel said. "They'll say 'Oh, I went to refill it two months ago, and then they didn't have it.'"

The other side: Some insurers told Axios they are covering the generic version of Flovent in cases it is medically necessary. That includes UnitedHealthcare, the nation's largest health insurer.

• "Given the manufacturer's decision to discontinue Flovent HFA in 2024, UnitedHealthcare's formulary will cover multiple cost-effective alternatives, including the branded generic for patients who may need it," a company spokesperson said.
• Others said the generic is included on some formularies, the list of covered drugs.
• Blue Cross and Blue Shield's coverage program for federal employees covers the generic on all of its commercial formularies, as well as two of its Medicare formularies, said a spokesperson for the association representing Blues plans.