Home Health iDBL
Interactive Drug Benefit List
DIN/NPN/PIN 02418401 ANORO ELLIPTA 62.5 MCG / DOSE * 25 MCG / DOSE INHALATION METERED INHALATION POWDER UMECLIDINIUM BROMIDE/ VILANTEROL TRIFENATATE
120000 AUTONOMIC DRUGS
120800 ANTICHOLINERGIC AGENTS
120808 ANTIMUSCARINICS / ANTISPASMODICS
Date Listed/Coverage Update: 01-Feb-2017
Unit Price: 2.9503
LCA Price: N/A
MAC Price:

N/A
Unit of Issue: Dose
Manufacturer: GLAXOSMITHKLINE (GSK)
ATC: R03AL03
1
Interchangeable Products: No
Coverage Status: STEP THERAPY/ SPECIAL AUTHORIZATION
Applies to Clients of: Non-Group Coverage (Group 1)
Coverage for Seniors (Group 66)
Palliative Coverage (Group 20514, Please note your client may have Group 1 or Group 66 coverage)
Child and Family Services (Group 20403)
Alberta Child Health Benefit (Group 20400)
Children and Youth Services (Group 19824)
Income Support (Group 19823)
Alberta Human Services (AISH) (Group 19823)
Alberta Adult Health Benefit (AAHB) (Group 23609)
Special Authorization Request Form:

Long-Acting Fixed-Dose Combination Products for Asthma/COPD Special Authorization Request Form (ABC 60025)

Expand all Collapse all



FIRST-LINE DRUG PRODUCT(S): LONG-ACTING BRONCHODILATOR (I.E., LONG-ACTING BETA-2 AGONIST [LABA] OR LONG-ACTING MUSCARINIC ANTAGONIST [LAMA])

"For the long-term maintenance treatment of airflow obstruction in patients with moderate to severe (i.e., FEV1 < 80% predicted) chronic obstructive pulmonary disease (COPD), who have an inadequate response to a long-acting bronchodilator (long-acting beta-2 agonist [LABA] or long-acting muscarinic antagonist [LAMA])."

"For the long-term maintenance treatment of airflow obstruction in patients with severe (i.e., FEV1 < 50% predicted) chronic obstructive pulmonary disease (COPD)."

"Special authorization may be granted for 24 months."

Note: If a claim for the Step therapy drug product is rejected, pharmacists can use their professional judgment to determine the appropriateness of using the intervention code(s) noted below to re-submit a claim. The pharmacist is responsible to document on the patient's record the rationale for using the second-line therapy drug.

UP - First-line therapy ineffective

All requests for umeclidinium bromide + vilanterol trifenatate must be completed using the Long-Acting Fixed-Dose Combination Products for Asthma/COPD Special Authorization Request Form (ABC 60025).

Review Status / Past Decisions

Indication Reviewing
Body		 Submission
Completion
Date		 CDR
Recommendation
Date		 Expert Committee
Recommendation
Date		 ADBL
Effective
Date		 CDR
Recommendation		 Review
Status
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) Expert Committee 2016/09/22 2017/02/01 Change to Step Therapy/Special Authorization
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) Common Drug Review 2014/03/05 2015/05/01 Under Review
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) Common Drug Review 2014/03/05 2015/01/15 View CDR - List with clinical criteria and/or conditions
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) Common Drug Review 2014/03/05 2015/06/01 Special Authorization
Indication CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
Reviewing
Body		 Expert Committee
Submission
Completion
Date		 2016/09/22
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date		 2017/02/01
CDR
Recommendation
Review
Status		 Change to Step Therapy/Special Authorization
Indication CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
Reviewing
Body		 Common Drug Review
Submission
Completion
Date		 2014/03/05
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date		 2015/05/01
CDR
Recommendation
Review
Status		 Under Review
Indication CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
Reviewing
Body		 Common Drug Review
Submission
Completion
Date		 2014/03/05
CDR
Recommendation
Date		 2015/01/15
Expert Committee
Recommendation
Date
ADBL
Effective
Date
CDR
Recommendation		 View
Review
Status		 CDR - List with clinical criteria and/or conditions
Indication CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
Reviewing
Body		 Common Drug Review
Submission
Completion
Date		 2014/03/05
CDR
Recommendation
Date
Expert Committee
Recommendation
Date
ADBL
Effective
Date		 2015/06/01
CDR
Recommendation
Review
Status		 Special Authorization
To return to the printable Drug Benefit List and related publications, click here
Last Updated:
NOTICE:
The DBL, DBS and related publications require knowledgeable interpretation and are intended primarily for professional health care practitioners, pharmacies, hospitals and organizations associated with the manufacture, distribution and use of pharmaceutical preparations.
Electronic versions of all DBL and DBS related publications are unofficial versions and are provided for convenience and private use only. Official paper versions can be obtained from Alberta Blue Cross who publishes them on behalf of Alberta Health and Alberta Human Services.
Alberta Health reserves the right to make changes, without notice, to the List through the Interactive DBL(iDBL), and any such changes to the Interactive DBL(iDBL) are effective the date of the change (unless otherwise stated) and regardless of the date of publication in the paper version or updates.