Limited Use Note(s)

FLUTICASONE FUROATE & UMECLIDINIUM BROMIDE & VILANTEROL TRIFENATATE100mcg & 62.5mcg & 25mcg Pd Inh-30 Dose Pk

Reason For Use Code	Clinical Criteria
567	For the long-term, once daily, maintenance treatment of airflow obstruction in patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and/or emphysema and to reduce exacerbations of COPD in patients with a history of exacerbations in patients who require a combination of an inhaled corticosteroid (ICS), long-acting muscarinic antagonist (LAMA), and a long-acting beta2-adrenergic agonist (LABA).
	LU Authorization Period: Indefinite.

Reason For Use Code

Clinical Criteria

567

For the long-term, once daily, maintenance treatment of airflow obstruction in patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and/or emphysema and to reduce exacerbations of COPD in patients with a history of exacerbations in patients who require a combination of an inhaled corticosteroid (ICS), long-acting muscarinic antagonist (LAMA), and a long-acting beta2-adrenergic agonist (LABA).

LU Authorization Period: Indefinite.

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