Limited Coverage Drugs – aclidinium bromide in combination with formoterol
Generic Name |
aclidinium bromide-formoterol |
---|---|
Strength |
aclidinium bromide 400 mcg/formoterol 12 mcg |
Form |
dry powder for oral inhalation |
Special Authority Criteria |
Approval Period |
---|---|
Diagnosis of moderate to very severe1 chronic obstructive pulmonary disease (COPD) where spirometry measures are as follows:
AND
AND Inadequate response after a minimum 6-month trial of either:
OR
Notes: 1Moderate to very severe COPD is defined as follows:
|
Indefinite |
Practitioner Exemptions
- Respirologists are not required to submit a Special Authority request form for coverage.
Special Notes
- In remote areas, where spirometry access is limited, spirometry measurements are to be provided within 6 months.
Special Authority Request Form(s)