Breztri Aeroshpere HFA (MDI)

Breztri Aeroshpere HFA (MDI)

budesonide/glycopyrronium/formoterol fumarate 160/7.2/5 mcg/dose

Duration:

12h

Instructions:

2 inhalations twice daily; maximum dose: 2 inhalations twice daily

Cost:

$161.88 for 120 doses

Limited Use Code: 638

For the long-term maintenance treatment of airflow obstruction in patients with 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 ICS, LAMA, and LABA. Authorization Period: Indefinite

Low Emissions

Trelegy Ellipta (DPI)

fluticasone furoate/umeclidinium/vilanterol 100/62.5/25 mcg/dose

Duration:

24h

Instructions:

one inhalation once daily

Cost:

100/62.5/25 mcg: $174.56 for 30 doses

Limited Use Code: 567

For the long-term, once daily, maintenance treatment of airflow obstruction in patients with 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 ICS, LAMA, and LABA. Authorization Period: Indefinite

Low Emissions

How to use a Genuair.pdf

Duaklir Genuair (DPI)

aclidinium bromide/formoterol fumarate 400/12 mcg/dose

Duration:

12h

Instructions:

1 inhalation twice daily

Cost:

$85.51 for 60 doses

Limited Use Code: 459

For the long-term treatment of patients with moderate to severe COPD who have a history of exacerbations and have had an inadequate response to a LABA or LAMA. Authorization Period: Indefinite

Low Emissions

Ultibro Breezhaler (DPI)

glycopyrronium/indacaterol 50/110 mcg/dose

Duration:

24h

Instructions:

contents of 1 capsule inhaled once daily using Breezhaler device

Cost:

$103.06 for 30 doses

Limited Use Code: 459

For the long-term treatment of patients with moderate to severe COPD who have a history of exacerbations and have had an inadequate response to a LABA or LAMA. Authorization Period: Indefinite

Low Emissions

How to use a Respimat.pdf

Anoro Ellipta (DPI)

umeclidinium/vilanterol 62.5/25 mcg/dose

Duration:

24h

Instructions:

one inhalation once daily

Cost:

$116.16 for 30 doses

Limited Use Code: 459

For the long-term treatment of patients with moderate to severe COPD who have a history of exacerbations and have had an inadequate response to a LABA or LAMA. Authorization Period: Indefinite

Low Emissions

Inspiolto Respimat (SMI)

tiotropium/olodaterol 2.5/2.5 mcg/dose

Duration:

24h

Instructions:

2 inhalations (5/5 mcg) once daily

Cost:

$87.47 for 60 doses

Limited Use Code: 459

For the long-term treatment of patients with moderate to severe COPD who have a history of exacerbations and have had an inadequate response to a LABA or LAMA. Authorization Period: Indefinite

Low Emissions

How to use a Handihaler.pdf

Spiriva Handihaler (DPI)

tiotropium bromide 18 mcg/dose

Duration:

24h

Instructions:

Contents of 1 capsule inhaled once daily using HandiHaler device. Note: To ensure drug delivery, the contents of each capsule should be inhaled twice

Cost:

$76.18 for 30 doses

Covered

Low Emissions

How to use a Genuair.pdf

Tudorza Genuair (DPI)

aclidinium bromide 400 mcg/dose

Duration:

12h

Instructions:

1 inhalation twice daily

Cost:

$74.09 for 60 doses

Covered

Low Emissions

Seebri Breezhaler (DPI)

glycopyrronium bromide 50 mcg/dose

Duration:

24h

Instructions:

contents of 1 capsule inhaled once daily using Breezhaler device

Cost:

$74.09 for 30 doses

Covered

Low Emissions

How to use a Respimat.pdf

Incruse Ellipta (DPI)

umeclidinium bromide 62.5 mcg/dose

Duration:

24h

Instructions:

one inhalation once daily

Cost:

$70.40 for 30 doses

Covered

Low Emissions

Spiriva Respimat (SMI)

tiotropium bromide 2.5 mcg/dose

Duration:

24h

Instructions:

2 inhalations (5 mcg) once daily

Cost:

$75.47 for 60 doses

Covered

Low Emissions

Serevent Diskus (DPI)

salmeterol 50 mcg/dose

Duration:

12h

Instructions:

one inhalation twice daily

Cost:

$96.08 for 60 doses

Limited Use Code: 391

For patients with moderate to severe COPD with persistent respiratory symptoms despite an adequate trial of, or an intolerance to, a regularly scheduled short-acting bronchodilator AND a long-acting anticholinergic. Authorization Period: Indefinite

High Emissions ~58.2 km driven by average gas-powered passenger vehicle

How to use a Respimat.pdf

Atrovent HFA (MDI)

ipratropium 20 mcg/dose

Duration:

4-6h

Instructions:

one to two puffs every 4 to 6 hours as needed (maximum 12 doses/day)

Cost:

$36.43 for 200 doses

Covered

Low Emissions

Combivent Respimat (SMI)

ipratropium/salbutamol 20/100 mcg/dose

Duration:

4-6h

Instructions:

one inhalation every 4 to 6 hours as needed (maximum: 6 inhalations/day)

Cost:

$48.70 for 120 doses

Not covered

High Emissions ~112.6 km driven by average gas-powered passenger vehicle

Ventolin HFA (MDI)

generic versions: apo-sabutamol, sanis-salbutamol salbutamol 100 mcg/dose

Duration:

4-6h

Adult Instructions (prevention of brochospasm):

one to two puffs every 4 to 6 hours as needed with an appropriate spacer device

Cost:

$20.29 for 200 doses

Covered

Moderate Emissions ~38.8 km driven by average gas-powered passenger vehicle

Teva-Salbutamol HFA or Airomir (MDI)

must include "no substition" on the Rx for this lower carbon option salbutamol 100 mcg/dose

Duration:

4-6h

one to two puffs every 4 to 6 hours as needed with an appropriate spacer device

Instructions:

one to two puffs every 4 to 6 hours as needed with an appropriate spacer device

Cost:

$18.45 for 200 doses

Covered

Low Emissions

How to use a Turbuhaler.pdf

Ventolin Diskus (DPI)

salbutamol 200 mcg/dose

Duration:

4-6h

Instructions:

one inhalation every 4 to 6 hours as needed (maximum 4 doses per day)

Cost:

$25.24 for 60 doses

Not covered

Low Emissions

Bricanyl Turbuhaler (DPI)

terbutaline 0.5 mg/dose

Duration:

4-6h

Instructions:

one inhalation every 4 hours as needed; if dose is ineffective may repeat after 5 minutes

Cost:

$23.88 for 120 doses

Covered

Low Emissions

Enerzair Breezhaler (DPI)

mometasone/glycopyrronium/indacaterol 160/50/150 mcg/dose

Age Indication:

adults (≥ 18 years)

Duration:

24h

Adult Instructions:

contents of 1 capsule (indacaterol 150 mcg/glycopyrrolate 50 mcg/mometasone 160 mcg) inhaled once daily (maximum dose: 1 capsule/day)

Cost:

$133.16 for 30 doses

Limited Use Code: 627

For the treatment of asthma in adult patients inadequately controlled with a maintenance combination of a long-acting beta-2 agonist (LABA) and a medium or high dose of an inhaled corticosteroid (ICS), who experienced one or more asthma exacerbations in the previous 12 months. Authorization Period: Indefinite

Low Emissions

Trelegy Ellipta (DPI)

fluticasone furoate/umeclidinium/vilanterol 100/62.5/25; 200/62.5/25 mcg/dose

Age Indication:

adults (≥18 years old)

Duration:

24h

Adult Instructions:

one inhalation once daily (maximum dose: fluticasone furoate 200 mcg/umeclidinium 62.5 mcg/vilanterol 25 mcg per day)

Cost:

100/62.5/25 mcg: $174.56 for 30 doses | 200/62.5/25 mcg: $190.20 for 30 doses

Not covered for asthma

Very High Emissions ~139 km driven by average gas-powered passenger vehicle

Zenhale HFA (MDI)

mometasone/formoterol fumarate 100/5; 200/5 mcg/dose

Age Indication:

adults and children ≥ 12 years

Duration:

12h

Adult Instructions:

two inhalation twice a day—dosage based on patient's asthma symptoms and severity (maximum dose: mometasone 200 mcg/formoterol 5 mcg twice daily)

Cost:

100/5 mcg: $128.94 for 120 doses | 200/5 mcg: $156.16 for 120 doses

Limited Use Code: 330

For the treatment of asthma in patients who are using optimum anti-inflammatory treatment and are still experiencing breakthrough symptoms. Authorization Period: Indefinite

High Emissions ~77.7 km driven by average gas-powered passenger vehicle

Advair HFA (MDI)

fluticasone propionate/salmeterol 125/25; 250/25 mcg/dose

Age Indication:

adults and children ≥ 12 years

Duration:

12h

Adult Instructions:

two inhalation twice a day—dosage based on patient's asthma symptoms and severity (Maximum dose: fluticasone propionate 1,000 mcg/day and salmeterol 100 mcg/day)

Cost:

125/25 mcg: $140.82 for 120 doses | 250/25 mcg: $195.31 for 120 doses

Limited Use Code: 330

For the treatment of asthma in patients who are using optimum anti-inflammatory treatment and are still experiencing breakthrough symptoms. Authorization Period: Indefinite

Low Emissions

Atectura Breezhaler (DPI)

mometasone/indacaterol 80/150; 160/150; 320/150 mcg/dose

Age Indication:

adults and children ≥ 12 years

Duration:

24h

Adult Instructions:

one inhalation once a day—dosage based on patient's asthma symptoms and severity

Cost:

80/150 mcg: $50.99 for 30 doses | 160/150 mcg: $61.01 for 30 doses | 320/150 mcg: $76.85

Limited Use Code: 626

For once-daily maintenance treatment of asthma in patients aged 12 years and older with reversible obstructive airways disease. Authorization Period: Indefinite

Low Emissions

Advair Diskus (DPI)

fluticasone propionate/salmeterol 100/50; 250/50; 500/50 mcg/dose

Age Indication:

adults and children ≥ 6 years

Duration:

12h

Adult Instructions:

one inhalation twice a day—dosage based on patient's asthma symptoms and severity (Maximum dose: fluticasone propionate 1,000 mcg/day and salmeterol 100 mcg/day)

Cost:

100/50 mcg: $119.45 for 60 doses | 250/50 mcg: $149.78 for 60 doses | 500/50 mcg: $208.01

Limited Use Code: 330

For the treatment of asthma in patients who are using optimum anti-inflammatory treatment and are still experiencing breakthrough symptoms. Authorization Period: Indefinite

Low Emissions

How to use an Inhub.pdf

Wixela Inhub (DPI)

fluticasone propionate/salmeterol 100/50; 250/50; 500/50 mcg/dose

Age Indication:

adults and children ≥ 6 years

Duration:

12h

Adult Instructions:

one inhalation twice a day—dosage based on patient's asthma symptoms and severity (Maximum dose: fluticasone propionate 1,000 mcg/day and salmeterol 100 mcg/day)

Cost:

100/50 mcg: $63.88 for 60 doses | 250/50 mcg: $71.31 for 60 doses | 500/50 mcg: $96.61

Limited Use Code: 330

For the treatment of asthma in patients who are using optimum anti-inflammatory treatment and are still experiencing breakthrough symptoms. Authorization Period: Indefinite

Low Emissions

How to use a Turbuhaler.pdf

Breo Ellipta (DPI)

fluticasone furoate/vilanterol 100/25; 200/25 mcg/dose

Age Indication:

adults (≥18 years old)

Duration:

24h

Adult Instructions:

one inhalation once daily (maximum: 1 inhalation [fluticasone furoate 200 mcg/vilanterol 25 mcg] once daily)

Cost:

100/25 mcg: $129.17 for 30 doses | 200/25 mcg: $194.82 for 30 doses

Limited Use Code: 330

For the treatment of asthma in patients who are using optimum anti-inflammatory treatment and are still experiencing breakthrough symptoms. Authorization Period: Indefinite

Low Emissions

Symbicort Turbuhaler (DPI)

budesonide/formoterol fumurate 100/6; 200/6 mcg/dose

Age Indication:

adults and children ≥ 12 years

Duration:

12h

Adult Instructions:

may be used as maintenance/controller only: 1-2 puffs twice a day (max: 4 puffs/day) or as part of a maintenance/controller PLUS reliever regimen (MART therapy): 1-2 puffs twice a day and 1 puff as needed (max 8 puffs/24 hours)—Individualize daily budesonide dose based on severity of symptoms

Cost:

100/6 mcg: $97.73 for 120 doses | 200/6 mcg: $121.10 for 120 doses

Limited Use Code: 330

For the treatment of asthma in patients who are using optimum anti-inflammatory treatment and are still experiencing breakthrough symptoms. Authorization Period: Indefinite

High Emissions ~81.3 km driven by average gas-powered passenger vehicle

Qvar HFA (MDI)

beclomethasone dipropionate 50; 100 mcg/dose

Age Indication:

adults and children ≥ 5 years

Duration:

12h

Adult Instructions:

use twice daily with an appropriate spacer device—dosage based on patient's asthma symptoms and severity (see below)

Cost:

50 mcg: $61.26 for 200 doses | 100 mcg: $106.85 for 200 doses

Covered

High Emissions ~48.8 km driven by average gas-powered passenger vehicle

Alvesco HFA (MDI)

ciclesonide 100; 200 mcg/dose

Age Indication:

adults and children ≥ 6 years

Duration:

24h

Adult Instructions:

use once daily with an appropriate spacer device—dosage based on patient's asthma symptoms and severity (see below)

Cost:

100 mcg: $70.19 for 120 doses | 200 mcg: $108.93 for 120 doses

Covered

High Emissions ~67.4 km driven by average gas-powered passenger vehicle

How to use a Twisthaler.pdf

Flovent HFA (MDI)

fluticasone propionate 50; 125; 250 mcg/dose

Age Indication:

adults and children ≥ 12 months of age

Duration:

12h

Adult Instructions:

use twice daily with an appropriate spacer device—dosage based on patient's asthma symptoms and severity (see below)

Cost:

50 mcg: $48.74 for 120 doses | 125 mcg: $40.08 for 120 doses | 250 mcg: $66.92 for 120 doses

Covered

Low Emissions

Asmanex Twisthaler (DPI)

mometasone furoate 100; 200; 400 mcg doses

Age Indication:

adults and children ≥ 6 years

Duration:

24h

Adult Instructions:

one inhalation once or twice daily—dose is based on patient's asthma severity (see below)

Cost:

100 mcg: $56.44 for 30 doses* | 200 mcg: $56.90 for 60 doses | 400 mcg: $98.90 for 60 doses or $56.90 for 30 doses

Covered

100 mcg not covered

Low Emissions

How to use a Respiclick.pdf

Aermony Respiclick (DPI)

fluticasone propionate 55; 113; 232 mcg/dose

Age Indication:

adults and children ≥ 12 years

Duration:

12h

Adult Instructions:

one inhalation twice daily, approximately 12 hours apart—dose is based on patient's asthma symptom and severity (see below)

Cost:

55 mcg: $32.07 for 60 doses | 113mcg: $49.46 for 60 doses | 232 mcg: $68.21 for 60 doses

Covered

Low Emissions

Flovent Diskus (DPI)

fluticasone propionate 100; 250; 500 mcg/dose

Age Indication:

adults and children ≥ 6 years

Duration:

12h

Adult Instructions:

one inhalation twice a day—dosage based on patient's asthma symptoms and severity (see below)

Cost:

100 mcg $48.75 for 60 doses | 250 mcg $73.26 for 60 doses | 500 mcg $107.84 for 60 doses

Covered

100 mcg not covered

Low Emissions

How to use a Turbuhaler device.pdf

Arnuity Ellipta (DPI)

fluticasone furoate 100; 200 mcg/dose

Age Indication:

adults and children ≥ 12 years

Duration:

24h

Adult Instructions:

one inhalation once daily (maximum 200 mcg a day) — dosage based on patient's asthma symptoms and severity (see below)

Cost:

100 mcg: $67.80 for 30 doses | 200 mcg: $119.65 for 30 doses

Covered

Low Emissions

Pulmicort Turbuhaler (DPI)

budesonide 100; 200; 400 mcg doses

Age Indication:

adults and children ≥ 6 years

Duration:

12h

Adult Instructions:

one inhalation twice a day—dosage based on patient's asthma symptoms and severity (see below)

Cost:

100 mcg: $54.55 for 200 doses | 200 mcg: $96.11 for 200 doses | 400 mcg: $134.93 for 200 doses

Covered

High Emissions ~112.6 km driven by average gas-powered passenger vehicle

Ventolin HFA (MDI)

generic versions: apo-sabutamol, sanis-salbutamol salbutamol 100 mcg/dose

Duration:

4-6h

Adult Instructions (prevention of brochospasm):

one to two puffs every 4 to 6 hours as needed with an appropriate spacer device

Cost:

$20.29 for 200 doses

Covered

Moderate Emissions ~38.8 km driven by average gas-powered passenger vehicle

Teva-Salbutamol HFA or Airomir (MDI)

must include "no substition" on the Rx for this lower carbon option salbutamol 100 mcg/dose

Duration:

4-6h

Adult Instructions (prevention of brochospasm):

one to two puffs every 4 to 6 hours as needed with an appropriate spacer device

Cost:

$18.45 for 200 doses

Covered

Low Emissions