Yupelri – NC Standard

Restricted Product(s)

• Yupelri™ (revefenacin solution)

FDA Approved Use

• For the maintenance treatment of patients with chronic obstructive pulmonary disease (COPD)

Criteria for Approval of Restricted Product(s)

1. The patient will be using Yupelri solution for the maintenance treatment of moderate to severe COPD; AND 
2. BOTH of the following: 
   1. The patient has had a trial and failure of a short-acting beta2-agonist inhaler/solution or a short-acting muscarinic antagonist inhaler/solution despite documented compliance; OR 
      1. The patient has a documented allergy, intolerance, or clinical contraindication to a short-acting beta2-agonist inhaler/solution or a short-acting muscarinic antagonist inhaler/solution; AND 
   2. The patient has had a trial and failure of a long-acting beta2-agonist inhaler/solution or a long-acting muscarinic antagonist inhaler/solution despite documented compliance; OR 
      1. The patient has a documented allergy, intolerance, or clinical contraindication to a long-acting beta2-agonist inhaler/solution or a long-acting muscarinic antagonist inhaler/solution; AND 
3. For formularies that exclude (non-formulary) the requested medication, Non-formulary Exception Criteria applies.
   
   Duration of Approval: 365 days (1 year)

References

all information referenced is from FDA package insert unless otherwise noted below.

Policy Implementation/Update Information

Criteria and treatment protocols are reviewed annually by the Blue Cross NC P&T Committee, regardless of change. This policy is reviewed in Q4 annually.

November 2023: Criteria Change: Changed policy name. Formatting changes.
November 2018: Original utilization management criteria issued.