LABA/ICS Combination
Drug - Inhaled LABA/ICS Combination (Inhaled Long-Acting Beta2-Agonist/Inhaled Corticosteroid Combination)
October 2017
Therapeutic area - Asthma/COPD
Preferred
- Advair Diskus (fluticasone/salmeterol) [GSK]
- Advair HFA (fluticasone/salmterol) [GSK]
- Dulera (mometasone and formoterol) [Merck Sharp & Dohme Corp.]
- Symbicort (budesonide/formoterol) [AstraZeneca]
Nonpreferred
- AirDuo™ Respiclick® (fluticasone/salmeterol) [Teva Respiratory, LLC.]
- fluticasone/salmeterol inhalation powder [Teva Pharmaceuticals, Ltd. ]
- Breo® Ellipta® (fluticasone/vilanterol) [GSK]
Approval criteria for nonpreferred AirDuo Respiclick and fluticasone-salmeterol inhalation powder
- Patient must be 12 years of age or older AND
- Patient has a diagnosis of asthma AND
- Patient has tried and failed at least two preferred inhaled LABA/ICS products
Approval criteria for nonpreferred Breo Ellipta
- Patient must be 18 years of age or older AND
- Patient has a diagnosis of asthma or COPD AND
- Patient has tried and failed at least two preferred inhaled LABA/ICS products
Quantity limits
1 inhaler per 30 days
Questions?
MHCP Provider Call Center 651-431-2700 or 800-366-5411
