Limited coverage criteria – indacaterol-glycopyrronium-mometasone furoate

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

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

1. Clinically 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

• Log in to eForms
• HLTH 5824 - Asthma Triple Inhaler (ICS-LABA-LAMA) (PDF, 656KB)