Bronchial Dilators, Misc

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PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required but eligible patients will encounter a co-pay at the pharmacy.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
albuterol sulfate ALBUTEROL SULFATE SYRUP    
albuterol sulfate ALBUTEROL SULFATE TAB ER 12H    
albuterol sulfate ALBUTEROL SULFATE TABLET    
cromolyn sodium CROMOLYN SODIUM AMPUL-NEB    
ephedrine sulfate/guaifenesin BRONKAID DUAL ACTION TABLET    
epinephrine BRONCHIAL MIST AER REFILL    
epinephrine BRONCHIAL MIST AER W/ADAP    
guaifenesin/dyphylline DILOR-G TABLET    
guaifenesin/theophylline QUIBRON CAPSULE    
isoetharine HCl ISOETHARINE HCL SOLUTION    
metaproterenol sulfate METAPROTERENOL SULFATE SYRUP    
metaproterenol sulfate METAPROTERENOL SULFATE TABLET    
racepinephrine HCl S2 RACEPINEPHRINE VIAL-NEB    
terbutaline sulfate TERBUTALINE SULFATE TABLET    
terbutaline sulfate TERBUTALINE SULFATE VIAL