Limited Coverage Drugs - glycopyrronium

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

Practitioner Exemptions

  • None

Special Notes

  • None

Special Authority Request Form(s)