Corticosteroids, Inhaled

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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
59310030240 QVAR REDIHALER beclomethasone dipropionate HFA AEROBA 40 mcg/actuation Y Y N  
59310030480 QVAR REDIHALER beclomethasone dipropionate HFA AEROBA 80 mcg/actuation Y Y N  
00186091612 PULMICORT FLEXHALER budesonide AER POW BA 180 mcg/actuation (160 mcg delivered) Y Y N  
61269051812 PULMICORT FLEXHALER budesonide AER POW BA 180 mcg/actuation (160 mcg delivered) Y Y N  
00186091706 PULMICORT FLEXHALER budesonide AER POW BA 90 mcg/actuation (80 mcg delivered) Y Y N  
00186091765 PULMICORT FLEXHALER budesonide AER POW BA 90 mcg/actuation (80 mcg delivered) Y Y N  
61269050906 PULMICORT FLEXHALER budesonide AER POW BA 90 mcg/actuation (80 mcg delivered) Y Y N  
00093681519 BUDESONIDE budesonide AMPUL-NEB 0.25 mg/2 mL N Y N Pharmacy PA
00093681545 BUDESONIDE budesonide AMPUL-NEB 0.25 mg/2 mL N Y N Pharmacy PA
00093681555 BUDESONIDE budesonide AMPUL-NEB 0.25 mg/2 mL N Y N Pharmacy PA
00093681573 BUDESONIDE budesonide AMPUL-NEB 0.25 mg/2 mL N Y N Pharmacy PA
00115168774 BUDESONIDE budesonide AMPUL-NEB 0.25 mg/2 mL N Y N Pharmacy PA
00115168776 BUDESONIDE budesonide AMPUL-NEB 0.25 mg/2 mL N Y N Pharmacy PA
00487960101 BUDESONIDE budesonide AMPUL-NEB 0.25 mg/2 mL N Y N Pharmacy PA
00487960130 BUDESONIDE budesonide AMPUL-NEB 0.25 mg/2 mL N Y N Pharmacy PA
16714001805 BUDESONIDE budesonide AMPUL-NEB 0.25 mg/2 mL N Y N Pharmacy PA
47335063148 BUDESONIDE budesonide AMPUL-NEB 0.25 mg/2 mL N Y N Pharmacy PA
47335063149 BUDESONIDE budesonide AMPUL-NEB 0.25 mg/2 mL N Y N Pharmacy PA
62135082284 BUDESONIDE budesonide AMPUL-NEB 0.25 mg/2 mL N Y N Pharmacy PA
64980063803 BUDESONIDE budesonide AMPUL-NEB 0.25 mg/2 mL N Y N Pharmacy PA
69097031832 BUDESONIDE budesonide AMPUL-NEB 0.25 mg/2 mL N Y N Pharmacy PA
69097031853 BUDESONIDE budesonide AMPUL-NEB 0.25 mg/2 mL N Y N Pharmacy PA
69097031886 BUDESONIDE budesonide AMPUL-NEB 0.25 mg/2 mL N Y N Pharmacy PA
69097031887 BUDESONIDE budesonide AMPUL-NEB 0.25 mg/2 mL N Y N Pharmacy PA
76282064037 BUDESONIDE budesonide AMPUL-NEB 0.25 mg/2 mL N Y N Pharmacy PA
76282064038 BUDESONIDE budesonide AMPUL-NEB 0.25 mg/2 mL N Y N Pharmacy PA
00186198804 PULMICORT budesonide AMPUL-NEB 0.25 mg/2 mL N Y N Pharmacy PA
00093681619 BUDESONIDE budesonide AMPUL-NEB 0.5 mg/2 mL N Y N Pharmacy PA
00093681645 BUDESONIDE budesonide AMPUL-NEB 0.5 mg/2 mL N Y N Pharmacy PA
00093681655 BUDESONIDE budesonide AMPUL-NEB 0.5 mg/2 mL N Y N Pharmacy PA
00093681673 BUDESONIDE budesonide AMPUL-NEB 0.5 mg/2 mL N Y N Pharmacy PA
00115168974 BUDESONIDE budesonide AMPUL-NEB 0.5 mg/2 mL N Y N Pharmacy PA
00115168976 BUDESONIDE budesonide AMPUL-NEB 0.5 mg/2 mL N Y N Pharmacy PA
00487970101 BUDESONIDE budesonide AMPUL-NEB 0.5 mg/2 mL N Y N Pharmacy PA
00487970130 BUDESONIDE budesonide AMPUL-NEB 0.5 mg/2 mL N Y N Pharmacy PA
16714001905 BUDESONIDE budesonide AMPUL-NEB 0.5 mg/2 mL N Y N Pharmacy PA
47335063248 BUDESONIDE budesonide AMPUL-NEB 0.5 mg/2 mL N Y N Pharmacy PA
47335063249 BUDESONIDE budesonide AMPUL-NEB 0.5 mg/2 mL N Y N Pharmacy PA
59651058505 BUDESONIDE budesonide AMPUL-NEB 0.5 mg/2 mL N Y N Pharmacy PA
59651058530 BUDESONIDE budesonide AMPUL-NEB 0.5 mg/2 mL N Y N Pharmacy PA
60687052479 BUDESONIDE budesonide AMPUL-NEB 0.5 mg/2 mL N Y N Pharmacy PA
60687052483 BUDESONIDE budesonide AMPUL-NEB 0.5 mg/2 mL N Y N Pharmacy PA
62135082384 BUDESONIDE budesonide AMPUL-NEB 0.5 mg/2 mL N Y N Pharmacy PA
64980063903 BUDESONIDE budesonide AMPUL-NEB 0.5 mg/2 mL N Y N Pharmacy PA
68180098405 BUDESONIDE budesonide AMPUL-NEB 0.5 mg/2 mL N Y N Pharmacy PA
68180098430 BUDESONIDE budesonide AMPUL-NEB 0.5 mg/2 mL N Y N Pharmacy PA
69097031932 BUDESONIDE budesonide AMPUL-NEB 0.5 mg/2 mL N Y N Pharmacy PA
69097031953 BUDESONIDE budesonide AMPUL-NEB 0.5 mg/2 mL N Y N Pharmacy PA
69097031986 BUDESONIDE budesonide AMPUL-NEB 0.5 mg/2 mL N Y N Pharmacy PA
69097031987 BUDESONIDE budesonide AMPUL-NEB 0.5 mg/2 mL N Y N Pharmacy PA
76204001801 BUDESONIDE budesonide AMPUL-NEB 0.5 mg/2 mL N Y N Pharmacy PA
76204001811 BUDESONIDE budesonide AMPUL-NEB 0.5 mg/2 mL N Y N Pharmacy PA
76282064137 BUDESONIDE budesonide AMPUL-NEB 0.5 mg/2 mL N Y N Pharmacy PA
76282064138 BUDESONIDE budesonide AMPUL-NEB 0.5 mg/2 mL N Y N Pharmacy PA
00186198904 PULMICORT budesonide AMPUL-NEB 0.5 mg/2 mL N Y N Pharmacy PA
00093681719 BUDESONIDE budesonide AMPUL-NEB 1 mg/2 mL N Y N Pharmacy PA
00093681745 BUDESONIDE budesonide AMPUL-NEB 1 mg/2 mL N Y N Pharmacy PA
00093681773 BUDESONIDE budesonide AMPUL-NEB 1 mg/2 mL N Y N Pharmacy PA
47335063348 BUDESONIDE budesonide AMPUL-NEB 1 mg/2 mL N Y N Pharmacy PA
47335063349 BUDESONIDE budesonide AMPUL-NEB 1 mg/2 mL N Y N Pharmacy PA
69097032132 BUDESONIDE budesonide AMPUL-NEB 1 mg/2 mL N Y N Pharmacy PA
69097032153 BUDESONIDE budesonide AMPUL-NEB 1 mg/2 mL N Y N Pharmacy PA
69097032186 BUDESONIDE budesonide AMPUL-NEB 1 mg/2 mL N Y N Pharmacy PA
69097032187 BUDESONIDE budesonide AMPUL-NEB 1 mg/2 mL N Y N Pharmacy PA
00186199004 PULMICORT budesonide AMPUL-NEB 1 mg/2 mL N Y N Pharmacy PA
70515071201 ALVESCO ciclesonide HFA AER AD 160 mcg/actuation N Y N Pharmacy PA
70515071205 ALVESCO ciclesonide HFA AER AD 160 mcg/actuation N Y N Pharmacy PA
70515071101 ALVESCO ciclesonide HFA AER AD 80 mcg/actuation N Y N Pharmacy PA
70515071105 ALVESCO ciclesonide HFA AER AD 80 mcg/actuation N Y N Pharmacy PA
00173087410 ARNUITY ELLIPTA fluticasone furoate BLST W/DEV 100 mcg Y Y N  
00173087414 ARNUITY ELLIPTA fluticasone furoate BLST W/DEV 100 mcg Y Y N  
66993016797 FLUTICASONE FUROATE fluticasone furoate BLST W/DEV 100 mcg Y Y N  
00173087610 ARNUITY ELLIPTA fluticasone furoate BLST W/DEV 200 mcg Y Y N  
00173087614 ARNUITY ELLIPTA fluticasone furoate BLST W/DEV 200 mcg Y Y N  
66993016897 FLUTICASONE FUROATE fluticasone furoate BLST W/DEV 200 mcg Y Y N  
00173088810 ARNUITY ELLIPTA fluticasone furoate BLST W/DEV 50 mcg Y Y N  
66993016697 FLUTICASONE FUROATE fluticasone furoate BLST W/DEV 50 mcg Y Y N  
59310020006 ARMONAIR DIGIHALER fluticasone propionate AER PW BAS 113 mcg/actuation N Y N Pharmacy PA
59310051508 ARMONAIR DIGIHALER fluticasone propionate AER PW BAS 113 mcg/actuation N Y N Pharmacy PA
59310052508 ARMONAIR DIGIHALER fluticasone propionate AER PW BAS 232 mcg/actuation N Y N Pharmacy PA
66993007996 FLUTICASONE PROPIONATE HFA fluticasone propionate AER W/ADAP 110 mcg/actuation N Y N Pharmacy PA
66993008096 FLUTICASONE PROPIONATE HFA fluticasone propionate AER W/ADAP 220 mcg N Y N Pharmacy PA
66993007896 FLUTICASONE PROPIONATE HFA fluticasone propionate AER W/ADAP 44 mcg N Y N Pharmacy PA
66993079197 FLUTICASONE PROPIONATE fluticasone propionate BLST W/DEV 100 mcg Y Y N  
66993079297 FLUTICASONE PROPIONATE fluticasone propionate BLST W/DEV 250 mcg Y Y N  
66993079097 FLUTICASONE PROPIONATE fluticasone propionate BLST W/DEV 50 mcg Y Y N  
78206011501 ASMANEX mometasone furoate AER POW BA 110 mcg/actuation (30 doses) Y Y N  
78206011401 ASMANEX mometasone furoate AER POW BA 220 mcg/actuation (120 doses) Y Y N  
78206011403 ASMANEX mometasone furoate AER POW BA 220 mcg/actuation (14 doses) Y Y N  
78206011404 ASMANEX mometasone furoate AER POW BA 220 mcg/actuation (30 doses) Y Y N  
78206011402 ASMANEX mometasone furoate AER POW BA 220 mcg/actuation (60 doses) Y Y N  
78206011201 ASMANEX HFA mometasone furoate HFA AER AD 100 mcg/actuation Y Y N  
78206011301 ASMANEX HFA mometasone furoate HFA AER AD 200 mcg/actuation Y Y N  
78206011101 ASMANEX HFA mometasone furoate HFA AER AD 50 mcg/actuation Y Y N  
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