Miscellaneous Pulmonary Agents
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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.
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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| montelukast sodium | MONTELUKAST SODIUM | TAB CHEW | Y | N | ||
| montelukast sodium | SINGULAIR | TABLET | Y | N | ||
| montelukast sodium | MONTELUKAST SODIUM | TABLET | Y | N | ||
| ensifentrine | OHTUVAYRE | AMPUL-NEB | N | Pharmacy PA | N | |
| roflumilast | DALIRESP | TABLET | N | Pharmacy PA | N | Feb 23, 2012 |
| zafirlukast | ACCOLATE | TABLET | N | N | ||
| zileuton | ZILEUTON ER | TBMP 12HR | N | N |