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
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    
montelukast sodium SINGULAIR GRAN PACK N    
montelukast sodium MONTELUKAST SODIUM GRAN PACK N    
roflumilast DALIRESP TABLET N PA Document Feb 23, 2012
roflumilast ROFLUMILAST TABLET N PA Document  
zafirlukast ZAFIRLUKAST TABLET N    
zafirlukast ACCOLATE TABLET N    
zileuton ZYFLO TABLET N