VA Criteria for Use Formulary Advisor Reference
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BUDESONIDE/ GLYCOPYRROLATE/ FORMOTEROL INHL,ORAL

Generic Name
BUDESONIDE/ GLYCOPYRROLATE/ FORMOTEROL INHL
Brand Names
BREZTRI AEROSPHERE
Drug Class
ANTIASTHMA,OTHER
Formulary Status
Prior Auth Required Formulary with prior authorization
Copay Tier
3
Last Updated
May 1, 2026

Clinical Criteria Summary

Document 231: Budesonide Glycopyrrolate Formoterol BREZTRI Criteria in Asthma

Indication & Clinical Status

  • Diagnosis of asthma or asthma/COPD overlap
  • Uncontrolled asthma symptoms and/or exacerbations
  • If currently receiving an ICS, patient is NOT a candidate for ICS de-escalation

Treatment History & Regimen Requirements

  • Receiving at least a moderate dose ICS/LABA
  • Requires additional maintenance treatment with LAMA
  • Uncontrolled asthma symptoms and/or exacerbations while using formulary LABA/LAMA + ICS or ICS/LABA + LAMA

Prescriber & Consultation Requirements

  • Initial prescription is by or in consultation with a VA/VA Community Care Pulmonologist, Allergist/Immunologist or designated expert

Adherence & Device Considerations

  • Documented difficulty adhering to 3-drug therapy via 2 separate inhalers (ICS/LABA + LAMA or LABA/LAMA + ICS)
  • Unable to use multiple inhalers due to underlying conditions (e.g., cognitive deficits, dexterity or visual impairment, etc.)

Management & Adjudication Guidelines

  • Assess adherence and inhaler technique and provide any needed patient education before switching to Breztri
  • Patients doing well on 3-drug therapy via 2 separate inhalers should not be switched solely for convenience; these cases require case-by-case adjudication

Document 860: Budesonide Glycopyrrolate Formoterol BREZTRI Criteria in COPD

Exclusion Criteria

  • None

Core Inclusion Criteria (All must be met)

  • Initial prescription is by or in consultation with a VA/VA Community Care Pulmonologist, Allergist/Immunologist or designated expert
  • Diagnosis of chronic obstructive pulmonary disease [COPD] (post-bronchodilator ratio of FEV1/FVC less than 70%)
  • Receiving ICS/LABA or LABA/LAMA but requires additional maintenance treatment for uncontrolled COPD symptoms and/or exacerbations
  • If currently receiving an ICS, patient is NOT a candidate for ICS de-escalation

Additional Inclusion Criteria (One of the following must be met)

  • Documented difficulty adhering to 3-drug therapy via 2 separate inhalers (ICS/LABA + LAMA or LABA/LAMA + ICS)
  • Unable to use multiple inhalers due to underlying conditions (e.g., cognitive deficits, dexterity or visual impairment, etc.)
  • Uncontrolled COPD symptoms and/or exacerbations while using formulary LABA/LAMA + ICS or ICS/LABA + LAMA

Clinical Management & Adjudication Requirements

  • Assess adherence and inhaler technique and provide any needed patient education before switching to Breztri
  • Patients doing well on 3-drug therapy via 2 separate inhalers should not be switched solely for convenience; these cases should be adjudicated on a case-by-case basis

Source Documents

Document 231: Budesonide Glycopyrrolate Formoterol BREZTRI Criteria in Asthma Document 860: Budesonide Glycopyrrolate Formoterol BREZTRI Criteria in COPD