Lonhala Magnair (glycopyrrolate inhalation solution) — United Healthcare
moderate to severe chronic obstructive pulmonary disease (COPD)
Preferred products
- Spiriva Handihaler
- Spiriva Respimat
- Yupelri
Initial criteria
- Diagnosis of moderate to severe chronic obstructive pulmonary disease (COPD)
- AND EITHER of the following:
- 1) History of failure, contraindication or intolerance to BOTH of the following:
- a) Spiriva Handihaler or Respimat (tiotropium)
- b) Yupelri (revefenacin inhalation solution)
- OR
- 2) BOTH of the following:
- a) Patient is unable to use a metered-dose, dry powder or slow mist inhaler (e.g. Spiriva Respimat) to control COPD due to ONE of the following:
- i) Cognitive or physical impairment limiting coordination of handheld devices (e.g., cognitive decline, arthritis in the hands) (Document impairment)
- ii) Patient is unable to generate adequate inspiratory force (peak inspiratory flow rate (PIFR) resistance <60 L/min)
- AND
- b) History of failure, contraindication or intolerance to Yupelri (revefenacin inhalation solution)
Reauthorization criteria
- Documentation of positive clinical response to therapy
Approval duration
12 months