Update on Asthma Management: the 2022 GINA Report
'The Worst Possible Time Of Year': Doctors Warn About Asthma Inhaler Switch Coming In January
Starting January 1, a drug that thousands of patients depend on to help them breathe will disappear from pharmacy shelves, and doctors are concerned patients may have delays switching to alternatives and getting them covered by insurance.
Manufacturer GSK has said it's discontinuing the branded asthma inhaler Flovent, and instead is making an "authorized generic" version, which is identical but without the same branding.
Physicians who treat patients with asthma say the authorized generic will work just as well as the branded drug, but it doesn't appear to be covered as widely by insurers. That may mean patients will have to obtain new prescriptions and sort out coverage hurdles at the height of respiratory virus season.
"This medication has been the most commonly used inhaled medication for the past 25 or 30 years," said Dr. Robyn Cohen, a pediatric pulmonologist at Boston Medical Center. "It's the one that, overwhelmingly, pediatricians reach for when they decide that their patient needs a daily preventive medication. ... The fact that it's being discontinued is going to be a huge shock to the system for patients, for families and for doctors."
Doctors are urging patients to take action now to ensure they've got their medicine heading into the new year and advocacy groups have been trying to get the word out.
But the story of why Flovent is disappearing, and the lack of insurance coverage for its ostensibly identical replacement, touches on some of the most complex facets of American health care and drug pricing.
Flovent will no longer be manufactured starting January 1 and an identical generic version will be available.
Martin Shields/Alamy
Major change to Medicaid's drug programA spokeswoman for GSK said the company is making the change "as part of our commitment to be ambitious for patients."
She noted the company introduced the authorized generics of Flovent HFA, an inhalation aerosol, and Flovent Diskus, an inhalation powder, in May 2022 and October 2023, and that, subsequently, it would discontinue manufacturing the branded versions in the United States on January 1, 2024.
The authorized generics, she said, "will provide patients in the US with potentially lower cost alternatives of these medically important products."
Experts who follow the industry both on Wall Street and in academia, though, point out GSK is making the switch at precisely the time a change in Medicaid rebates could cause the company to have to pay large penalties because of price increases on Flovent over a number of years.
The legal change coming into effect on the first of the year removes a cap on Medicaid rebates that companies are required to pay if they raise the price of medicines more than inflation.
"Flovent Diskus has been on the market since 2000 and Flovent HFA since 2004, and GSK has hiked the price on both products numerous times since their launch," Dr. William Feldman, an associate physician in the Division of Pulmonary and Critical Care Medicine at Brigham and Women's Hospital who studies asthma drugs, told CNN. "These are precisely the sort of drugs that will be affected by the new policy eliminating the Medicaid rebate cap."
Until now, the rebates were capped at the total price of a drug, so manufacturers would never pay more than a drug costs back to Medicaid.
But under a provision in the 2021 American Rescue Plan Act, that limit was removed, and starting January 1, 2024, drugs that have been subject to large price increases over time could end up incurring rebates to Medicaid that are greater than their price - meaning pharmaceutical companies would sell those drugs to Medicaid at a loss.
"Obviously pharma doesn't want to be selling at a loss on anything in its portfolio," said Andrew Baum, an analyst who covers the stock of GSK and other pharmaceutical companies for the financial firm Citi. "So it seeks to evade impact by, one: discontinuation; two: authorized generic."
An authorized generic, Baum told CNN, is viewed as a separate product, "but still enables pharma to collect some of the economics."
Or, put another way, it's the same product without the branding and also without the history of price increases that would leave the medicine vulnerable to such large rebates to Medicaid.
According to data from GoodRx, the price of branded Flovent has gone up about 47% since 2014.
Other drugmakers have made changes ahead of the January 1 rebate cap removal as well; makers of insulin this year announced major price cuts - of 70% or more - on their products, a move analysts estimate will save them hundreds of millions of dollars a year.
The authorized generic strategy GSK is employing "is a way, broadly speaking, to maximize the profitability of the product in question," said David Amsellem, a financial analyst who covers the industry at investment firm Piper Sandler.
He noted there are currently no other generic versions of Flovent approved by the FDA.
GSK did price the authorized generic lower than branded Flovent; one package of Flovent HFA in the 110 microgram dose, for example, costs $273.83, about 50% more than the $177.99 wholesale acquisition cost of its authorized generic counterpart, according to prices the company shared with CNN. The wholesale acquisition cost is the price before insurance and rebates.
But CVS Caremark, a major pharmacy benefit manager that determines which medicines are covered by insurance for its members, is giving preferential placement to another branded inhaler, Pulmicort, on its formulary, instead of the authorized generic versions of Flovent.
"In this case, the authorized generics were more expensive than the brand name medications," a CVS spokesman told CNN. He noted that's based on net prices, rather than the wholesale acquisition cost, meaning Pulmicort could be less expensive because of rebates its manufacturer, AstraZeneca, pays to obtain better insurance coverage.
'The worst possible time of year'The fact that insurance plans aren't broadly covering the authorized generic of Flovent, said BMC's Cohen, "means that patients are going to need to get a brand new prescription for a completely different medication in the middle of the worst possible time of year, which is the winter respiratory virus season."
For patients with persistent asthma, Cohen said, Flovent has been the most commonly used daily preventive anti-inflammatory medication for decades. It shrinks swelling in the airways and reduces the body's exaggerated response to triggers that make it hard to breathe.
During cold and flu season, she said, it becomes even more crucial to have that daily medicine.
"Flu, Covid, RSV - all these circulating viruses that are going around right now - are one of the biggest, if not the biggest, triggers for asthma attacks in kids," Cohen said. "This is what leads to kids being in the emergency room."
Cohen said she's concerned that patients, as well as physicians and pharmacists, don't know this change with Flovent is coming, and they need to act now to work out alternatives and determine insurance coverage.
For some groups, the alternatives are more limited. For patients with a more rare inflammatory condition, called eosinophilic esophagitis, Flovent HFA is one of the most commonly prescribed topical steroids, and other medicines don't have as much data supporting their use in the condition, said Dr. Erin Syverson, an attending physician in the Division of Gastroenterology, Hepatology and Nutrition at Boston Children's Hospital.
As EoE affects the esophagus, patients swallow the medicine instead of breathing it in, and it can tame the inflammation that can cause pain with swallowing or food getting stuck, requiring procedures to remove it. In kids, Syverson said, EoE can lead to recurrent vomiting, heartburn, belly aches, and trouble making progress starting solid foods, and Flovent can help keep the condition under control.
"With the discontinuation coming up, I worry it's going to just be one more hurdle for this patient population that already has very limited medications available to them," Syverson told CNN. "I don't know what January is going to be like, but I'm worried."
CNN's Tami Luhby contributed to this report.
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A Guide To Bra Alternatives For Every Occasion
Going braless is more common than it used to be, thanks to the many bra alternatives that exist these days. Every lingerie department is filled with plenty of options, from adhesive bras and nipple covers to boob tape. That's not to say you should throw out your traditional underwire bras, but different outfits may require you to have backup options for a more seamless look.
Like with traditional bras, finding the right alternative can take a bit of experimenting. While some may have mastered the art of boob tape, others gravitate toward a simple bralette. Personal preferences, as well as a product's features, can dictate the bra alternative you reach for. Not every style will give you the lift and support you need or a no-show appearance, depending on your chosen outfit.
We tapped two undergarment experts to help us explain every bra alternative and their uses. Keep scrolling for the full breakdown, plus products to shop in each category to wear with your next bra-free outfit.
meet the expertBest Alternative Investment Platforms
Looking for ways to diversify your portfolio and boost returns? This list of the best alternative investment platforms is a great place to start.
Different financial advisors take different approaches to investing. But the piece of advice that nearly all of them give almost all of their clients is to diversify their portfolio. The logic behind this is simple. Even the best investments go through down cycles, which means putting all your investment eggs in 1 basket is inherently risky. Diversifying your portfolio minimizes the risk that all your investments go south at the same time. One of the best ways to diversify your portfolio is by making alternative investments.
Quick Look: Best Alt Invest Platforms
Best Alternative Investing Platforms
One of the miracles of the internet is how much smaller it has made the world of investing. Before the internet, if you wanted to make an alternative investment in wine or art, you'd have to have a wine cellar or warehouse to store it in. Then you'd have to arrange security and insurance for the investments. It would literally be a full-time job.
But thanks to the internet, there are now dozens of alternative investment platforms where you can pick and choose what to invest in while someone else does the heavy lifting. Some of Benzinga's favorite alternative platforms are listed below.
Best for Investing in Rental Homes: Ark7
securely through ark7's website
Best For:
Accredited and Non-Accredited Investors
Ark7 makes money by charging a sourcing fee and an asset management fee on its investments. Its sourcing fee is equal to 3% of the property market cap (determined by the property's net operating income and dividing it by its value.)
Ark7 serves as a fractional real estate investing platform that wants to make it easier for you to access rental properties. This means that you're not buying into a REIT or trying to find a specific property to buy. You have control over the properties where your money goes, you can expand or contract your portfolio as much as you like, and it's available to accredited and non-accredited investors.
There's no minimum on this platform, there are no commissions for transactions and you can review the portfolio to see what interests you most. Yes, the sourcing fees may seem to be a bit high, but the platform still makes it easier than ever to get into the property sector.
Best for Fractional Real Estate: Arrived Homes
Arrived Homes is one of the newest and fastest growing crowdfunding platforms on the internet. The company allows non-accredited investors to buy shares in carefully selected rental properties.
The minimum investment is only $100, making it easy to start earning passive income from property investments and to diversify across multiple properties. Investors simply collect quarterly dividends from their properties while waiting for the asset to increase in value over time. Arrived Homes takes care of finding tenants as well as all of the management
Best for Real Estate Crowdfunding: CrowdStreet
CrowdStreet is a real estate crowdfunding platform that offers investors the chance to purchase equity shares in various real estate investments around the country. It's a great way to get involved in property investing, but you must be an accredited investor to buy into any CrowdStreet offerings. That means only investors who pass a certain net worth threshold are eligible.
If you are accredited, CrowdStreet offers some great investment opportunities with the potential for very high returns. The downside is that the minimum buy-ins are on the high side, and most CrowdStreet investments don't pay dividends for several years.
Best for Employers and Employees: EquityBee
EquityBee is an excellent alternative investment platform, providing investors with access to startups and growing firms. At the same time, startups and companies with big ideas can access retail investors through EquityBee—broadening their reach.
Employees can use the platform to push their stock options back into the firm and take part in its future success.
Investors can use EquityBee to diversify their investments, gain access to companies that have no IPO'd or even make their first investments in the private sector.
By funding employee stock options, EquityBee makes it possible to serve both team members and investors. With a minimum investment of $10,000, EquityBee allows you to get in on the ground level today.
Best for Trading Ideas: Public.Com
If you want to diversify your portfolio beyond stocks, ETFs, and crypto, you may be looking at alternative assets as a new investment vehicle. Public.Com recently launched alternative assets on their platform—meaning you can now invest in art, collectibles, and more right from their app.
You can use the interactive interface to learn more about each asset you choose before buying, and you can track the movement of each asset so that you know your investments are truly performing.
If you're not sure what to buy or when to sell, you can check out the social feed to learn what other traders are doing. Perhaps they'll lend you some inspiration.
Plus, there's a massive educational section where you can learn all about alternative assets and how they should fit into your portfolio. All of this happens on your mobile phone or tablet and you don't need any investing experience to get started.
Best for Accredited Investors: DLP Capital
DLP Capital functions as a private financial and real estate investment firm that allows you access to large cities and attainable workforce housing. The solutions and investment products that are provided both inform and enlighten the individual investor, and the platform as a whole has never missed a payment distribution to investors. Plus, the platform has never lost investor principal.
While the platform is only designed accredited investors, you can expect regular distributions after gaining access to workforce housing projects along with some tax benefits that may come with these investments.
All investments are subject to an intensive screening process, and due diligence is complete on each property just as would be done with a standard investment or property management company.
Every investment is highly liquid, these investments do not correlate with the stock market and allows you to diversify your portfolio even more than before. Plus, all returns are paid to investors before fees are removed.
Best for Non-Accredited Investors: Cityfunds by Nada
When you invest in Cityfunds by Nada, you can invest in a piece of a city for as little as $250. Anyone can buy into the program at any time with this small minimum deposit, and you are putting your stake into a piece of a city.
The firm invests in residential properties in a particular market, especially high-demand markets like Miami, Dallas and Austin. You can also buy and sell your shares in these cities like stocks so that you aren't relying on a particular development to see a return.
In short, Cityfunds by Nada combines what you love about ETFs with what is the largest asset class in the world. Plus, you can get yourself on the waitlist for the Nada Card, a debit card that will allow you to earn rewards that you can invest further in your real estate portfolio.
Best for Investors Looking for a Diverse Range of Offerings: EquityMultiple
EquityMultiple is a new alternative investment platform that uses technology to make property investing easier to understand for the investor, especially when you need help choosing the right investments. There are short-term and long-term growth options, and you can make the most of the cash you invest by pinpointing the real estate in which you would like to invest, without buying properties yourself.
In short, EquityMultiple offers:
Remember, this platform is only for accredited investors, but it allows you to do the hands-on work that you do with your other investments. You can learn all the information you need to know, but you're never tasked with managing these properties. You simply see the profits when they come in.
Best for Diverse Range of Offerings: Yieldstreet
Yieldstreet offers an all-in-one alternative investment platform with offerings for non-accredited investors as well as offerings available to accredited investors only. Yieldstreet regularly has new investment opportunities available, ranging from commercial real estate, art equity funds, structured notes, portfolios of consumer debt and many others.
Even if you're not quite ready to jump into one of Yieldstreet's offerings, it's worth signing up for the platform to gain access to the many webinars and educational content available to learn the ins and outs of various types of alternative investments.
Best for Investors Aiming to Diversify Their Real Estate Portfolios: Kay Properties & Investments
When investors, such as yourself, look into real estate, they often cringe at the idea of buying and managing properties outright. There are other ways to enter the real estate market, however, and one of the most overlooked is the DST 1031 exchange. At Kay Properties & Investments, you can diversify your portfolio with passive ownership or find properties for your 1031 or 1033 exchange.
You can use the properties you find through Kay to:
With these tax-smart investment options, you can begin to build a portfolio that doesn't require you to carry debt or hire a massive staff to manage each new property. Remember, the platform is only available to accredited investors, but there are experts available to answer your questions, 25 sponsor companies that make the magic possible and 200 years of experience for every investor to fall back on, making a DST a quality option for your portfolio.
Best for Real Estate Notes: Groundfloor
Groundfloor is an alternative real estate investing platform that offers investments in high-yield, short-term property loans. The platform is open to non-accredited investors and private individuals looking for active real estate alternative investment. Groundfloor has great volume with an average of 50-70 investments available at any given time..
Individuals with small portfolios will also like the low $10 minimum and 0 investor fees. The low minimum investment allows investors to easily diversify their Groundfloor portfolio across multiple loan offerings.
Best for Commercial Real Estate Insights: Placer.Ai
When you're looking for the best and most current information on commercial real estate properties, you can turn to Placer.Ai for assistance. This platform helps you make decisions based on available data, which can even include residential, retail, brokerage, government, finance and hospitality listings.
You learn quite a bit from Placer.Ai, including:
Using this platform, you can review any property in any state across the country. You can even search the city, state and ZIP code, depending on your needs. This is a simple way to identify new business opportunities or to learn the truth of a property in which you are already interested.
Best for Art: Masterworks
This alternative investment platform is based on fine art. It identifies select artists and buys works, which are then registered with the Securities and Exchange Commission (SEC) as a regulation A share offering. Investors will then share in the profits when the artwork they've invested in is sold.
Masterworks features works from famous artists both living and dead. In fact, it even has works by Banksy — the pseudonym of the England-based Street artist. This is, however, a long-term investment. Unlike investment real estate, there is no residual income generated by Masterworks investments, and investors must be willing to wait for several years before earning a dividend.
Best for Wine: Vint
Anyone who has ever been to a fancy restaurant and ordered a bottle of wine knows it can be expensive. That's because wine is produced in finite quantities, and fine wine is in high demand worldwide. That makes it a great alternative investment. Vint allows retail investors to benefit from the price increased caused by this high demand with its wine investment platform.
Vint has the buying power, industry connections and knowledge necessary to gain access to the most sought-after wines on the market at attractive prices before they reach peak value. The company also makes it possible for individual investors to gain access to these wines with a much smaller minimum investment than seeking these bottles out on their own.
Best for Watches: Bezel
The luxury watch market has been growing of late, and Bezel allows you to enter this market without hunting in antique shops or social media marketplaces. Launched in 2022, Bezel offers a highly curated selection of luxury timepieces from household names like Cartier, Rolex, Tag Heuer, Tiffany and more.
Bezel's mobile app is just as easy to use as its website, and the catalog appeals to both new collectors and timepiece enthusiasts or even those looking for that one special watch.
At Bezel, you gain peace of mind and get the value you deserve with:
While Bezel is only available in the U.S., it's the best way for you to invest in watches, add value to a diverse portfolio, adorn your wrist with some luxury, find the perfect gift or resell a watch that lost its spot in your rotation.
What is an Alternative Investment?
Any investment you make in something outside of stocks and bonds is considered an alternative investment. It may sound exotic but in reality, people have been making alternative investments for a long time. Historically, real estate and gold are two of the most popular alternative investments. You can diversify your portfolio by making alternative investments as supplements to your stocks and bonds, or you can have a portfolio that consists entirely of different alternative investments.
Types of Alternative Investments
As discussed in the section above, real estate and gold are two of the most commonly held alternative investments. With that said, there is a multitude of alternative investments you can make. Here are some of the most popular options:
Diversify With Preferred Alternative Investments
Alternative investments may sound like a fancy, New Age concept, but that's far from the truth. In fact, if you own property, you have already made an alternative investment. Many people who see the wisdom of investing, but are put off by the volatility of the stock market, have been gravitating toward alternative investments for quite some time. With that said, it's important to remember that there is an incredible variety of alternative investments outside of real property or even gold. The rise of internet-based alternative investment platforms has opened up a whole new world to potential investors.
Now you can buy shares of startup companies, wine futures and even sports collectibles as alternative investments. Some have high payoffs and an elevated risk level, while others may require investor accreditation and the ability to wait a long time before earning a dividend.
Other alternative investments have an active secondary market that allows you to liquidate your shares quickly. The variety is nearly limitless. Alternative investments can be a great way to diversify your portfolio, but you still must consider the risks and choose wisely. As always, Benzinga is a great place to go for neutral information on all the pluses and minuses.
Frequently Asked Questions
A
Any investments made in something aside from stocks and bonds are considered to be alternative investments. Examples of popular alternative investments include the following: gold, real estate, wine, sports collectibles, startups, art, cryptocurrency.
A
The answer to that question depends on several factors, and the answer will vary depending on the needs of each investor. Long-term, accredited investors might like REITs, but there are also real estate offerings for nonaccredited investors as well.
Other investors may already have real estate holdings and want to buy into niche investments that pique their personal interests such as wine or sports collectibles. In all cases, investors have to consider their liquidity and individual risk tolerance before deciding what investment is best for them. What might be right for one, may not be right for another.
A
Yes, alternative investments can be profitable, but they generate profit in different ways. For example, real estate may generate steady income while wine, watches and collectibles may only generate income when they are sold.
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