Limited Coverage Drugs - mometasone furoate in combination with formoterol

Generic Name

mometasone furoate-formoterol

Strength

mometasone furoate 100 mcg or 200 mcg/formoterol 5 mcg

Form

suspension for oral inhalation

Special Authority Criteria

Approval Period

Diagnosis of asthma

AND

inadequate response on optimal dose of inhaled corticosteroid.

Indefinite

Practitioner Exemptions

  • Respirologists and allergists are not required to submit a Special Authority request form for coverage.

Special Notes

  • None

Special Authority Request Form(s)