Limited coverage drugs – glycopyrronium

Last updated on October 6, 2022

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Generic name	glycopyrronium
Strength	50 µg
Form	dry powder for oral inhalation

Special Authority criteria	Approval period
Diagnosis of chronic obstructive pulmonary disease (COPD) AND Failure after a minimum one-month trial of each of the Regular Benefit long-acting muscarinic receptor antagonist (LAMA) products¹ Notes: ¹The Regular Benefit LAMA products are the following: tiotropium (Spiriva^® Respimat^®) umeclidinium (Incruse^® Ellipta^®)	Indefinite

Special Authority criteria

Approval period

Diagnosis of chronic obstructive pulmonary disease (COPD)

AND

Failure after a minimum one-month trial of each of the Regular Benefit long-acting muscarinic receptor antagonist (LAMA) products¹

Notes:

¹The Regular Benefit LAMA products are the following:

tiotropium (Spiriva^® Respimat^®)
umeclidinium (Incruse^® Ellipta^®)

Indefinite

Practitioner exemptions

None

Special notes

None

Special Authority request form(s)

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HLTH 5362 - COPD form (PDF, 100KB)

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Limited coverage drugs – glycopyrronium

Practitioner exemptions

Special notes

Special Authority request form(s)