We've been dealing with this exact issue with Flovent for my son.

Amusingly our insurance's captive/preferred pharmacy wants to mail us the generic for $40 + 25 S+H instead of us buying it locally for $150. Except that they can't climate control the shipment and it's 20F over the rated temp of the inhaler here today, in the shade. So their in house pharmacist allowed an override.

Still a royal PITA.

This is a really good summary. It is mentioned by worth reiterating that evergreening does not prevent generic competition of the origional formulation or configuration. I think it is a bit of a misnomer to refer to these as patent lifetime extensions.

Having spend decades work with pharma companies, I agree that one of the main issues is missaligned incentives between patients and PBMs/health plans.

Bad patents are hard to quantify but a big part of picture. Should the patent office rejected Flovent + HFA as obvious? Another example would be Novarits patents on VEGF in silicone syringes. Litigating a global patent fight with Pharma companies with billions at stake is a huge barrier. The best way to prevent this IMO is more disgression in initial patent issue.

I once encountered a small scale smuggling operation in which prisoners were smuggling their inhalers out of a prison to sell on the street.

The prisoners were receiving as much as $10 per inhaler, funded by a family on the outside that couldn't afford the inhalers at pharmacy prices.