Bronchial Dilators, Misc
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 |
|---|---|---|---|---|---|---|
| albuterol sulfate | ALBUTEROL SULFATE | SYRUP | N | |||
| albuterol sulfate | ALBUTEROL SULFATE | TABLET | N | |||
| cromolyn sodium | CROMOLYN SODIUM | AMPUL-NEB | N | |||
| epinephrine | PRIMATENE MIST | HFA AER AD | N | |||
| formoterol fumarate/nebulizer | FORMOTEROL FUMARATE-NEBULIZER | VIAL-NEB | N | |||
| guaifenesin/dyphylline | DILOR-G | TABLET | N | |||
| guaifenesin/theophylline | QUIBRON | CAPSULE | N | |||
| isoetharine HCl | ISOETHARINE HCL | SOLUTION | N | |||
| racepinephrine HCl | S2 RACEPINEPHRINE | VIAL-NEB | N | |||
| terbutaline sulfate | TERBUTALINE SULFATE | TABLET | N | |||
| terbutaline sulfate | TERBUTALINE SULFATE | VIAL | N |