Limited coverage criteria – indacaterol-glycopyrronium-mometasone furoate

Last updated on March 18, 2025

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Generic name		indacaterol-glycopyrronium-mometasone furoate
Strength & form		150 mcg indacaterol/50 mcg glycopyrronium/160 mcg mometasone furoate powder hard capsules for inhalation

Special Authority criteria	Approval period
Diagnosis of asthma AND Inadequate response with a maintenance combination of an optimal dose of a long-acting beta-2 agonist (LABA) AND a moderate to high dose of an inhaled corticosteroid AND Have experienced one or more asthma exacerbations in the previous 12 months¹	Indefinite

Special Authority criteria

Approval period

Diagnosis of asthma

AND

Inadequate response with a maintenance combination of an optimal dose of a long-acting beta-2 agonist (LABA) AND a moderate to high dose of an inhaled corticosteroid

AND

Have experienced one or more asthma exacerbations in the previous 12 months¹

Indefinite

Practitioner exemptions

Respirologists and allergists are invited to apply for individual specialist exemption from completing the SA form. A Collaborative Prescribing Agreement is available for respirologists and allergists practicing in B.C. by invitation only

Special notes

¹Clinically significant asthma exacerbation is defined as worsening of asthma symptoms, requiring administration of systemic corticosteroids (i.e., intravenous steroids or oral corticosteroids for at least 3 days), and/or an emergency department visit, and/or hospitalization

Special Authority request form(s)

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