Limited coverage criteria – mometasone furoate in combination with formoterol

Last updated on March 19, 2025

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

Generic name	mometasone furoate-formoterol
Strength & form	mometasone furoate 100 mcg or 200 mcg/formoterol 5 mcg 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 for coverage

Special Authority request form(s)

Log in to eForms
HLTH 5328 – General Special Authority request (PDF, 656KB)

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Limited coverage criteria – mometasone furoate in combination with formoterol

Generic name

Strength & form

Special Authority criteria

Approval period

Practitioner exemptions

Special Authority request form(s)