Limited Coverage Drugs - Indacaterol Maleate

Generic Name

indacaterol maleate
Strength 75 mcg
Form micronized powder for inhalation

Special Authority Criteria

Approval Period

Diagnosis of chronic obstructive pulmonary disease (COPD)

AND

Inadequate response to optimal short-acting beta-agonist therapy

AND

Dosage does not exceed 75 mcg per day.

Indefinite

Practitioner Exemptions

  • Respirologists are not required to submit a Special Authority Request form for coverage

Special Notes

  • None

Special Authority Request Form

Note: The above SA form is for LABA single entity inhaler only. For LAMA criteria and related form, see indacaterol in combination with glycopyrronium.