Limited Coverage Drugs - Umeclidinium

Generic Name

Umeclidinium
Strength

Umeclidinium 62.5 mcg

Form dry powder for oral inhalation via inhaler
Special Authority Criteria Approval Period

Diagnosis of Chronic Obstructive Pulmonary Disease (COPD), where spirometry measures are:

  • Forced expiratory volume in 1 second (FEV1) as a percentage of predicted value (less than or equal to 65%)
    AND
  • Ratio of actual FEV1/forced vital capacity (FVC) (less than 0.7)
    AND
  • Inadequate response after a 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 daily1

Notes:

  1. 12 puffs of ipratropium via 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.
  • Patients who meet the Special Authority criteria for aclidinium/glycopyrronium/tiotropium will automatically receive coverage of umeclidinium.

Additional Information

  • None

Special Authority Request Form