Limited coverage drugs – mometasone furoate in combination with formoterol

Last updated on October 6, 2022

Special Authority requests can now be submitted online. It's simple and quick!

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

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)

Log in to eForms
HLTH 5328 - General form for asthma (PDF, 523KB)

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Limited coverage drugs – mometasone furoate in combination with formoterol

Practitioner exemptions

Special notes

Special Authority request form(s)