Trelegy® Ellipta®

Drug - Trelegy® Ellipta® (fluticasone furoate, umecldinium bromide and vilanterol trifenatate powder) [GlaxoSmithKline LLC.]

February 2018

Therapeutic area - COPD

Approval criteria

• Patient must be at least 18 years old AND
• Patient has a diagnosis of chronic obstructive pulmonary disease (COPD) AND
• Patient has a trial and failure (as defined by continued symptoms, including exacerbations) of adequate treatment with 2 preferred dual combination therapies (e.g., inhaled corticosteroid plus long-acting beta-agonist or long-acting beta-agonist plus long-acting antimuscarinic) AND
• Patient does not have known hypersensitivity to milk proteins, fluticasone, umeclidinium, vilanterol, or other known excipients

Renewal criteria

• Patient continues to meet criteria defined for initial approval AND
• Documentation of continued efficacy via prescribers expert opinion on patient evaluation AND
• Patient has not experienced any intolerable adverse effects (e.g., hypersensitivity, bronchospasm, worsening of intraocular pressure, increased severe infections)

Quantity limits

One inhaler (30 blister strips) per 30 days

Questions?

MHCP Provider Call Center 651-431-2700 or 800-366-5411