Limited coverage drugs – glycopyrronium

Last updated on August 27, 2024

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Generic name		glycopyrronium
Strength & form		50 mcg dry powder for oral inhalation

Special Authority criteria	Approval period
Diagnosis of chronic obstructive pulmonary disease (COPD) AND Failure after a minimum one-month trial of each of the regular benefit long-acting muscarinic antagonist (LAMA)¹ molecules (i.e., umeclidinium and one of the tiotropium inhalers)	Indefinite

Special Authority criteria

Approval period

Diagnosis of chronic obstructive pulmonary disease (COPD)

AND

Failure after a minimum one-month trial of each of the regular benefit long-acting muscarinic antagonist (LAMA)¹ molecules (i.e., umeclidinium and one of the tiotropium inhalers)

Indefinite

Practitioner exemptions

None

Special notes

¹The regular benefit LAMA products are the following:
- tiotropium inhalation solution
- tiotropium dry powder inhaler
- umeclidinium dry powder inhaler

Special Authority requests

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HLTH 5362 – COPD form (PDF, 100KB)

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