![]() ![]() *Combination agents that contain a Tier-1 ingredient qualify as Tier-1 agents. umeclidinium inhalation powder (Incruse™ Ellipta®).revefenacin inhalation solution (Yupelri™).glycopyrrloate inhalation solution (Lonhala™ Magnair™).aclidinium inhalation powder (Tudorza® PressAir ®).tiotropium soft mist inhaler (Spiriva® Respimat®).tiotropium inhalation powder (Spiriva® HandiHaler ®).olodaterol inhalation spray Striverdi® Respimat®).indacaterol inhalation powder (Arcapta®).arformoterol nebulizer solution Brovana®).formoterol nebulizer solution (Perforomist®).salmeterol inhalation powder (Serevent®).Prior Authorization form Long-Acting Beta2 Agonists (LABA) and Long-Acting Anticholinergics (LAMA) A clinical exception may apply for members who are unable to effectively use hand-actuated devices, such as Spiriva ® HandiHaler ®, or who are stable on nebulized therapy.A documented adverse effect, drug interaction, or contraindication to all available Tier-1 products or.A 4-week trial of at least 1 LABA and a 4-week trial of 1 LAMA within the past 90 days or.An FDA approved diagnosis of chronic obstructive pulmonary disease (COPD), chronic bronchitis, or emphysema and.Member must be 18 years of age or older and.Long-Acting Beta 2 Agonist (LABA) and Long-Acting Muscarinic Antagonist (LAMA) Tier-2 Approval Criteria: Tier-1 products are covered without authorization levalbuterol HFA (Xopenex HFA) ( generic ).albuterol sulfate inhalation powder ( ProAir® Digihaler™ ).albuterol HFA ( Ventolin® HFA ) ( generic ).albuterol HFA ( Proventil® HFA ) ( generic ).albuterol HFA ( ProAir® HFA ) ( generic ).In addition, a patient-specific, clinically significant reason why the member cannot transition to Tier-1 medications must be provided. For continuation consideration, documentation demonstrating positive clinical response and member compliance greater than 80% with prescribed maintenance therapy must be provided. Approvals will be for the duration of 3 months.The member’s phone camera must be functional and able to scan the inhaler QR code and register the ProAir® Digihaler™ inhaler AND.The member should be capable and willing to use the Companion Mobile App and follow the Instructions for Use and ensure the ProAir® Digihaler™ Companion Mobile App is compatible with their specific smartphone AND.The prescriber agrees to closely monitor member adherence AND. ![]() A patient-specific, clinically significant reason why the member requires the ProAir® Digihaler™ formulation over all available Tier-1 medications must be provided AND.An FDA approved or clinically accepted indication AND.ProAir ® Digihaler ® (Albuterol Sulfate Inhalation Powder) Approval Criteria:: ![]()
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