Glycopyrrolate (Lonhala Magnair®)

SELF ADMINISTRATION

Indications for Prior Authorization:

  • Long-term maintenance treatment of airflow obstruction in patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and/or emphysema

Patients must meet the following criteria for the indication(s) above:

  • Diagnosis of COPD, AND
  • Member is at least 18 years or older, AND
  • Member has a documented need for nebulized LAMA therapy (e.g. impaired dexterity, altered cognition, or chronic muscle weakness), AND
  • Member has tried and failed preferred Yupelri

Dosing:

  • 1 vial in the morning and 1 vial in the evening every day
  • Store vials in the foil pouch and only remove immediately before use with Magnair

Approval:

  • 1 year

Last review date: April 23, 2019