Corticosteroids/Beta-Agonist Combination, Inhaled
PDL Reference Documents
Drug Use Review Documents
Newsletters
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 |
|---|---|---|---|---|---|---|
| budesonide/formoterol fumarate | BREYNA | HFA AER AD | Y | N | ||
| budesonide/formoterol fumarate | BUDESONIDE-FORMOTEROL FUMARATE | HFA AER AD | Y | N | ||
| budesonide/formoterol fumarate | SYMBICORT | HFA AER AD | Y | N | ||
| fluticasone propion/salmeterol | AIRDUO RESPICLICK | AER POW BA | Y | N | ||
| fluticasone propion/salmeterol | FLUTICASONE-SALMETEROL | AER POW BA | Y | N | ||
| fluticasone propion/salmeterol | FLUTICASONE-SALMETEROL | BLST W/DEV | Y | N | ||
| fluticasone propion/salmeterol | WIXELA INHUB | BLST W/DEV | Y | N | ||
| fluticasone propion/salmeterol | ADVAIR DISKUS | BLST W/DEV | Y | N | ||
| fluticasone propion/salmeterol | FLUTICASONE-SALMETEROL HFA | HFA AER AD | Y | N | ||
| fluticasone propion/salmeterol | ADVAIR HFA | HFA AER AD | Y | N | ||
| mometasone/formoterol | DULERA | HFA AER AD | Y | N | ||
| albuterol sulfate/budesonide | AIRSUPRA | HFA AER AD | N | N | ||
| fluticasone propion/salmeterol | AIRDUO DIGIHALER | AER PW BAS | N | N | ||
| fluticasone/vilanterol | BREO ELLIPTA | BLST W/DEV | N | N | ||
| fluticasone/vilanterol | FLUTICASONE-VILANTEROL | BLST W/DEV | N | N |