Limited Coverage Drugs - Aclidinium

Generic Name

aclidinium

Strength

400 mcg
Form oral inhalation powder

Special Authority Criteria

Approval Period

Diagnosis of chronic obstructive pulmonary disease (COPD) where spirometry measures are:

  • FEV1 as a percentage of predicted value (less than or equal to 65%)

AND

  • Ratio of actual FEV1/ FVC (less than 0.7)

AND

  • Inadequate response after 3 month trial of either:
    • ipratropium at a dose of 12 puffs daily.

OR

  • ipratropium and salbutamol combination inhaler (Combivent Respimat) at a dose of 6 puffs daily.1

Notes:

  1. 12 puffs of ipratropium via metered dose inhaler is equivalent to 6 puffs of ipratropium via Combivent Respimat inhaler.

Indefinite

Practitioner Exemptions

  • Practitioners in the following specialty are not required to submit a Special Authority request form for coverage:
    • Respirology.

Special Notes

  • In remote areas, where spirometry access is limited, spirometry measurements are to be provided within 6 months.

Special Authority Request Form(s)