Beta-Agonists, Inhaled Short-Acting

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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.

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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Carveout
‐ Bill FFS		 Current Drug Use Criteria
50111080132 ALBUTEROL albuterol AER REFILL 90 mcg N Y N  
59310058020 PROAIR RESPICLICK albuterol sulfate AER POW BA 90 mcg N Y N  
59310011720 PROAIR DIGIHALER albuterol sulfate AER PW BAS 90 mcg N Y N  
59310054020 PROAIR DIGIHALER albuterol sulfate AER PW BAS 90 mcg N Y N  
00054074287 ALBUTEROL SULFATE HFA albuterol sulfate HFA AER AD 90 mcg Y Y N  
00093317431 ALBUTEROL SULFATE HFA albuterol sulfate HFA AER AD 90 mcg Y Y N  
00781729685 ALBUTEROL SULFATE HFA albuterol sulfate HFA AER AD 90 mcg Y Y N  
17270074000 ALBUTEROL SULFATE HFA albuterol sulfate HFA AER AD 90 mcg Y Y N  
45802008801 ALBUTEROL SULFATE HFA albuterol sulfate HFA AER AD 90 mcg Y Y N  
60687066291 ALBUTEROL SULFATE HFA albuterol sulfate HFA AER AD 90 mcg Y Y N  
66993001968 ALBUTEROL SULFATE HFA albuterol sulfate HFA AER AD 90 mcg Y Y N  
68180096301 ALBUTEROL SULFATE HFA albuterol sulfate HFA AER AD 90 mcg Y Y N  
69097014260 ALBUTEROL SULFATE HFA albuterol sulfate HFA AER AD 90 mcg Y Y N  
72572001401 ALBUTEROL SULFATE HFA albuterol sulfate HFA AER AD 90 mcg Y Y N  
76282067942 ALBUTEROL SULFATE HFA albuterol sulfate HFA AER AD 90 mcg Y Y N  
00173068220 VENTOLIN HFA albuterol sulfate HFA AER AD 90 mcg Y Y N  
00173068224 VENTOLIN HFA albuterol sulfate HFA AER AD 90 mcg Y Y N  
00378705752 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 0.63 mg/3 mL Y Y N  
00378705798 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 0.63 mg/3 mL Y Y N  
00487030101 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 0.63 mg/3 mL Y Y N  
00591346753 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 0.63 mg/3 mL Y Y N  
50742039205 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 0.63 mg/3 mL Y Y N  
50742039225 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 0.63 mg/3 mL Y Y N  
59651018305 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 0.63 mg/3 mL Y Y N  
59651018325 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 0.63 mg/3 mL Y Y N  
59651018330 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 0.63 mg/3 mL Y Y N  
62135082684 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 0.63 mg/3 mL Y Y N  
76204001001 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 0.63 mg/3 mL Y Y N  
76204001005 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 0.63 mg/3 mL Y Y N  
76204001011 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 0.63 mg/3 mL Y Y N  
76204001055 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 0.63 mg/3 mL Y Y N  
00378705852 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 1.25 mg/3 mL Y Y N  
00378705898 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 1.25 mg/3 mL Y Y N  
00487990401 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 1.25 mg/3 mL Y Y N  
00487990425 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 1.25 mg/3 mL Y Y N  
00591346853 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 1.25 mg/3 mL Y Y N  
50742039305 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 1.25 mg/3 mL Y Y N  
50742039325 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 1.25 mg/3 mL Y Y N  
59651018405 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 1.25 mg/3 mL Y Y N  
59651018425 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 1.25 mg/3 mL Y Y N  
59651018430 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 1.25 mg/3 mL Y Y N  
62135082784 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 1.25 mg/3 mL Y Y N  
76204001101 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 1.25 mg/3 mL Y Y N  
76204001105 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 1.25 mg/3 mL Y Y N  
76204001111 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 1.25 mg/3 mL Y Y N  
76204001155 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 1.25 mg/3 mL Y Y N  
00487990130 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 2.5 mg/0.5 mL Y Y N  
62135082984 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 2.5 mg/0.5 mL Y Y N  
64980064203 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 2.5 mg/0.5 mL Y Y N  
76204002701 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 2.5 mg/0.5 mL Y Y N  
76204002711 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 2.5 mg/0.5 mL Y Y N  
00378827031 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 2.5 mg/3 mL (0.083 %) Y Y N  
00378827052 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 2.5 mg/3 mL (0.083 %) Y Y N  
00378827055 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 2.5 mg/3 mL (0.083 %) Y Y N  
00378827062 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 2.5 mg/3 mL (0.083 %) Y Y N  
00378827064 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 2.5 mg/3 mL (0.083 %) Y Y N  
00378827091 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 2.5 mg/3 mL (0.083 %) Y Y N  
00378827093 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 2.5 mg/3 mL (0.083 %) Y Y N  
00487950100 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 2.5 mg/3 mL (0.083 %) Y Y N  
00487950101 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 2.5 mg/3 mL (0.083 %) Y Y N  
00487950103 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 2.5 mg/3 mL (0.083 %) Y Y N  
00487950125 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 2.5 mg/3 mL (0.083 %) Y Y N  
00487950160 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 2.5 mg/3 mL (0.083 %) Y Y N  
47335070348 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 2.5 mg/3 mL (0.083 %) Y Y N  
47335070349 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 2.5 mg/3 mL (0.083 %) Y Y N  
47335070352 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 2.5 mg/3 mL (0.083 %) Y Y N  
47335070354 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 2.5 mg/3 mL (0.083 %) Y Y N  
60687039579 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 2.5 mg/3 mL (0.083 %) Y Y N  
60687039583 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 2.5 mg/3 mL (0.083 %) Y Y N  
62135082884 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 2.5 mg/3 mL (0.083 %) Y Y N  
65862085801 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 2.5 mg/3 mL (0.083 %) Y Y N  
65862085805 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 2.5 mg/3 mL (0.083 %) Y Y N  
65862085825 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 2.5 mg/3 mL (0.083 %) Y Y N  
65862085830 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 2.5 mg/3 mL (0.083 %) Y Y N  
65862085860 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 2.5 mg/3 mL (0.083 %) Y Y N  
76204020001 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 2.5 mg/3 mL (0.083 %) Y Y N  
76204020025 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 2.5 mg/3 mL (0.083 %) Y Y N  
76204020030 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 2.5 mg/3 mL (0.083 %) Y Y N  
76204020060 ALBUTEROL SULFATE albuterol sulfate VIAL-NEB 2.5 mg/3 mL (0.083 %) Y Y N  
00093414545 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 0.31 mg/3 mL N Y N  
00093414556 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 0.31 mg/3 mL N Y N  
00115993076 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 0.31 mg/3 mL N Y N  
00115993078 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 0.31 mg/3 mL N Y N  
00378969052 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 0.31 mg/3 mL N Y N  
00378969062 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 0.31 mg/3 mL N Y N  
35573044325 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 0.31 mg/3 mL N Y N  
47335074349 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 0.31 mg/3 mL N Y N  
76204070001 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 0.31 mg/3 mL N Y N  
76204070011 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 0.31 mg/3 mL N Y N  
76204070015 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 0.31 mg/3 mL N Y N  
76204070025 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 0.31 mg/3 mL N Y N  
00093414645 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 0.63 mg/3 mL N Y N  
00093414656 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 0.63 mg/3 mL N Y N  
00115993176 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 0.63 mg/3 mL N Y N  
00115993178 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 0.63 mg/3 mL N Y N  
00378969152 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 0.63 mg/3 mL N Y N  
00378969162 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 0.63 mg/3 mL N Y N  
35573044425 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 0.63 mg/3 mL N Y N  
47335074649 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 0.63 mg/3 mL N Y N  
76204080001 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 0.63 mg/3 mL N Y N  
76204080011 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 0.63 mg/3 mL N Y N  
76204080015 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 0.63 mg/3 mL N Y N  
76204080025 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 0.63 mg/3 mL N Y N  
00378699331 LEVALBUTEROL CONCENTRATE levalbuterol HCl VIAL-NEB 1.25 mg/0.5 mL N Y N  
00378699393 LEVALBUTEROL CONCENTRATE levalbuterol HCl VIAL-NEB 1.25 mg/0.5 mL N Y N  
65862094203 LEVALBUTEROL CONCENTRATE levalbuterol HCl VIAL-NEB 1.25 mg/0.5 mL N Y N  
65862094250 LEVALBUTEROL CONCENTRATE levalbuterol HCl VIAL-NEB 1.25 mg/0.5 mL N Y N  
00093414845 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 1.25 mg/3 mL N Y N  
00093414856 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 1.25 mg/3 mL N Y N  
00115993276 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 1.25 mg/3 mL N Y N  
00115993278 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 1.25 mg/3 mL N Y N  
00378969252 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 1.25 mg/3 mL N Y N  
00378969262 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 1.25 mg/3 mL N Y N  
35573044525 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 1.25 mg/3 mL N Y N  
47335075349 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 1.25 mg/3 mL N Y N  
76204090001 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 1.25 mg/3 mL N Y N  
76204090011 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 1.25 mg/3 mL N Y N  
76204090015 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 1.25 mg/3 mL N Y N  
76204090025 LEVALBUTEROL HCL levalbuterol HCl VIAL-NEB 1.25 mg/3 mL N Y N  
00591292754 LEVALBUTEROL TARTRATE HFA levalbuterol tartrate HFA AER AD 45 mcg/actuation N Y N  
27437005601 XOPENEX HFA levalbuterol tartrate HFA AER AD 45 mcg/actuation N Y N  
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