Limited Coverage Drugs – Vilanterol – fluticasone furoate

Generic Name

vilanterol – fluticasone furoate

Strength

25 mcg vilanterol - 100 mcg fluticasone furoate, 25 mcg vilanterol - 200 mcg fluticasone furoate

Form

dry powder inhaler

Special Authority Criteria

Approval Period

1. Diagnosis of asthma

PLUS

inadequate response on optimal dose of inhaled corticosteroid

OR

2. Diagnosis of COPD

PLUS

inadequate response on optimal short acting beta agonist therapy.

Indefinite

Practitioner Exemptions

  • Practitioners in the following specialties are not required to submit a Special Authority request form for coverage:
    • Respirologists
    • Allergists

Special Notes

  • None

Special Authority Request Form(s)