Limited Use Note(s)

BUDESONIDE&GLYCOPYRRONIUM (GLYCOPYRRONIUM BROMIDE)&FORMOTEROL FUMARATE DIHYDRATE160mcg & 7.2mcg & 5mcg/Act Metered Dose Inh-120 Dose Pk

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Reason For Use Code	Clinical Criteria
638	For the long-term 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

638

For the long-term 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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