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 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
Current Drug Use Criteria New Drug Evaluation
montelukast sodium SINGULAIR TAB CHEW Y    
montelukast sodium MONTELUKAST SODIUM TAB CHEW Y    
montelukast sodium MONTELUKAST SODIUM TABLET Y    
montelukast sodium SINGULAIR TABLET Y    
benralizumab FASENRA SYRINGE N PA Document  
mepolizumab NUCALA VIAL N PA Document  
montelukast sodium SINGULAIR GRAN PACK N    
montelukast sodium MONTELUKAST SODIUM GRAN PACK N    
omalizumab XOLAIR SYRINGE N PA Document  
omalizumab XOLAIR VIAL N PA Document  
reslizumab CINQAIR VIAL N PA Document  
roflumilast DALIRESP TABLET N PA Document Feb 23, 2012
zafirlukast ZAFIRLUKAST TABLET N    
zafirlukast ACCOLATE TABLET N    
zileuton ZYFLO TABLET N    
zileuton ZILEUTON ER TBMP 12HR N    
zileuton ZYFLO CR TBMP 12HR N