DIN/NPN/PIN 02441888 INSPIOLTO RESPIMAT 2.5 MCG / DOSE * 2.5 MCG / DOSE INHALATION SOLUTION TIOTROPIUM BROMIDE MONOHYDRATE/ OLODATEROL HYDROCHLORIDE |
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Date Listed/Coverage Update: | 01-Feb-2017 | ||||||
Unit Price: | 1.0692 | ||||||
LCA Price: | N/A | ||||||
MAC Price: |
N/A |
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Unit of Issue: | Dose | ||||||
Manufacturer: | BOEHRINGER INGELHEIM (CANADA) LTD. (BOE) | ||||||
ATC: | R03BB54 | ||||||
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: | |
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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 tiotropium bromide monohydrate + olodaterol hydrochloride must be completed using the Long-Acting Fixed-Dose Combination Products for Asthma/COPD Special Authorization Request Form (ABC 60025). |
Review Status / Past Decisions
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