Muscarinic Antagonists, Inhaled
PDL Reference Documents
Newsletters
- August 2023 - 2023 Global Initiative for Chronic Obstructive Lung Disease Report: Focus on Revised Recommendations for Inhaler Products
- May 2017 - Updates in the Management of Chronic Obstructive Pulmonary Disease
- June 2013 - Updates and Future Perspectives in the Management of Stable Chronic Obstructive Pulmonary Disease
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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|
| 70515000201 | TUDORZA PRESSAIR | aclidinium bromide | AER POW BA | 400 mcg/actuation | N | Y | |
| 70515000202 | TUDORZA PRESSAIR | aclidinium bromide | AER POW BA | 400 mcg/actuation | N | Y | |
| 00597008717 | ATROVENT HFA | ipratropium bromide | HFA AER AD | 17 mcg/actuation | Y | Y | |
| 00378797031 | IPRATROPIUM BROMIDE | ipratropium bromide | SOLUTION | 0.2 mg/mL (0.02 %) | Y | Y | |
| 00378797052 | IPRATROPIUM BROMIDE | ipratropium bromide | SOLUTION | 0.2 mg/mL (0.02 %) | Y | Y | |
| 00378797055 | IPRATROPIUM BROMIDE | ipratropium bromide | SOLUTION | 0.2 mg/mL (0.02 %) | Y | Y | |
| 00378797062 | IPRATROPIUM BROMIDE | ipratropium bromide | SOLUTION | 0.2 mg/mL (0.02 %) | Y | Y | |
| 00378797064 | IPRATROPIUM BROMIDE | ipratropium bromide | SOLUTION | 0.2 mg/mL (0.02 %) | Y | Y | |
| 00378797091 | IPRATROPIUM BROMIDE | ipratropium bromide | SOLUTION | 0.2 mg/mL (0.02 %) | Y | Y | |
| 00378797093 | IPRATROPIUM BROMIDE | ipratropium bromide | SOLUTION | 0.2 mg/mL (0.02 %) | Y | Y | |
| 00487980100 | IPRATROPIUM BROMIDE | ipratropium bromide | SOLUTION | 0.2 mg/mL (0.02 %) | Y | Y | |
| 00487980101 | IPRATROPIUM BROMIDE | ipratropium bromide | SOLUTION | 0.2 mg/mL (0.02 %) | Y | Y | |
| 00487980125 | IPRATROPIUM BROMIDE | ipratropium bromide | SOLUTION | 0.2 mg/mL (0.02 %) | Y | Y | |
| 00487980130 | IPRATROPIUM BROMIDE | ipratropium bromide | SOLUTION | 0.2 mg/mL (0.02 %) | Y | Y | |
| 00487980160 | IPRATROPIUM BROMIDE | ipratropium bromide | SOLUTION | 0.2 mg/mL (0.02 %) | Y | Y | |
| 47335070648 | IPRATROPIUM BROMIDE | ipratropium bromide | SOLUTION | 0.2 mg/mL (0.02 %) | Y | Y | |
| 47335070649 | IPRATROPIUM BROMIDE | ipratropium bromide | SOLUTION | 0.2 mg/mL (0.02 %) | Y | Y | |
| 47335070652 | IPRATROPIUM BROMIDE | ipratropium bromide | SOLUTION | 0.2 mg/mL (0.02 %) | Y | Y | |
| 47335070654 | IPRATROPIUM BROMIDE | ipratropium bromide | SOLUTION | 0.2 mg/mL (0.02 %) | Y | Y | |
| 60687039479 | IPRATROPIUM BROMIDE | ipratropium bromide | SOLUTION | 0.2 mg/mL (0.02 %) | Y | Y | |
| 60687039483 | IPRATROPIUM BROMIDE | ipratropium bromide | SOLUTION | 0.2 mg/mL (0.02 %) | Y | Y | |
| 62135083084 | IPRATROPIUM BROMIDE | ipratropium bromide | SOLUTION | 0.2 mg/mL (0.02 %) | Y | Y | |
| 64980064002 | IPRATROPIUM BROMIDE | ipratropium bromide | SOLUTION | 0.2 mg/mL (0.02 %) | Y | Y | |
| 64980064003 | IPRATROPIUM BROMIDE | ipratropium bromide | SOLUTION | 0.2 mg/mL (0.02 %) | Y | Y | |
| 64980064006 | IPRATROPIUM BROMIDE | ipratropium bromide | SOLUTION | 0.2 mg/mL (0.02 %) | Y | Y | |
| 76204010001 | IPRATROPIUM BROMIDE | ipratropium bromide | SOLUTION | 0.2 mg/mL (0.02 %) | Y | Y | |
| 76204010025 | IPRATROPIUM BROMIDE | ipratropium bromide | SOLUTION | 0.2 mg/mL (0.02 %) | Y | Y | |
| 76204010030 | IPRATROPIUM BROMIDE | ipratropium bromide | SOLUTION | 0.2 mg/mL (0.02 %) | Y | Y | |
| 76204010060 | IPRATROPIUM BROMIDE | ipratropium bromide | SOLUTION | 0.2 mg/mL (0.02 %) | Y | Y | |
| 00378967130 | IPRATROPIUM-ALBUTEROL | ipratropium/albuterol sulfate | AMPUL-NEB | 0.5 mg-3 mg (2.5 mg base)/3 mL | Y | Y | |
| 00378967131 | IPRATROPIUM-ALBUTEROL | ipratropium/albuterol sulfate | AMPUL-NEB | 0.5 mg-3 mg (2.5 mg base)/3 mL | Y | Y | |
| 00378967160 | IPRATROPIUM-ALBUTEROL | ipratropium/albuterol sulfate | AMPUL-NEB | 0.5 mg-3 mg (2.5 mg base)/3 mL | Y | Y | |
| 00378967164 | IPRATROPIUM-ALBUTEROL | ipratropium/albuterol sulfate | AMPUL-NEB | 0.5 mg-3 mg (2.5 mg base)/3 mL | Y | Y | |
| 00378967193 | IPRATROPIUM-ALBUTEROL | ipratropium/albuterol sulfate | AMPUL-NEB | 0.5 mg-3 mg (2.5 mg base)/3 mL | Y | Y | |
| 00487020100 | IPRATROPIUM-ALBUTEROL | ipratropium/albuterol sulfate | AMPUL-NEB | 0.5 mg-3 mg (2.5 mg base)/3 mL | Y | Y | |
| 00487020101 | IPRATROPIUM-ALBUTEROL | ipratropium/albuterol sulfate | AMPUL-NEB | 0.5 mg-3 mg (2.5 mg base)/3 mL | Y | Y | |
| 00487020103 | IPRATROPIUM-ALBUTEROL | ipratropium/albuterol sulfate | AMPUL-NEB | 0.5 mg-3 mg (2.5 mg base)/3 mL | Y | Y | |
| 00487020160 | IPRATROPIUM-ALBUTEROL | ipratropium/albuterol sulfate | AMPUL-NEB | 0.5 mg-3 mg (2.5 mg base)/3 mL | Y | Y | |
| 47335075648 | IPRATROPIUM-ALBUTEROL | ipratropium/albuterol sulfate | AMPUL-NEB | 0.5 mg-3 mg (2.5 mg base)/3 mL | Y | Y | |
| 47335075649 | IPRATROPIUM-ALBUTEROL | ipratropium/albuterol sulfate | AMPUL-NEB | 0.5 mg-3 mg (2.5 mg base)/3 mL | Y | Y | |
| 47335075652 | IPRATROPIUM-ALBUTEROL | ipratropium/albuterol sulfate | AMPUL-NEB | 0.5 mg-3 mg (2.5 mg base)/3 mL | Y | Y | |
| 60687040579 | IPRATROPIUM-ALBUTEROL | ipratropium/albuterol sulfate | AMPUL-NEB | 0.5 mg-3 mg (2.5 mg base)/3 mL | Y | Y | |
| 60687040583 | IPRATROPIUM-ALBUTEROL | ipratropium/albuterol sulfate | AMPUL-NEB | 0.5 mg-3 mg (2.5 mg base)/3 mL | Y | Y | |
| 62135083184 | IPRATROPIUM-ALBUTEROL | ipratropium/albuterol sulfate | AMPUL-NEB | 0.5 mg-3 mg (2.5 mg base)/3 mL | Y | Y | |
| 64980064503 | IPRATROPIUM-ALBUTEROL | ipratropium/albuterol sulfate | AMPUL-NEB | 0.5 mg-3 mg (2.5 mg base)/3 mL | Y | Y | |
| 64980064506 | IPRATROPIUM-ALBUTEROL | ipratropium/albuterol sulfate | AMPUL-NEB | 0.5 mg-3 mg (2.5 mg base)/3 mL | Y | Y | |
| 69097017348 | IPRATROPIUM-ALBUTEROL | ipratropium/albuterol sulfate | AMPUL-NEB | 0.5 mg-3 mg (2.5 mg base)/3 mL | Y | Y | |
| 69097017353 | IPRATROPIUM-ALBUTEROL | ipratropium/albuterol sulfate | AMPUL-NEB | 0.5 mg-3 mg (2.5 mg base)/3 mL | Y | Y | |
| 69097017364 | IPRATROPIUM-ALBUTEROL | ipratropium/albuterol sulfate | AMPUL-NEB | 0.5 mg-3 mg (2.5 mg base)/3 mL | Y | Y | |
| 69097084034 | IPRATROPIUM-ALBUTEROL | ipratropium/albuterol sulfate | AMPUL-NEB | 0.5 mg-3 mg (2.5 mg base)/3 mL | Y | Y | |
| 69097084053 | IPRATROPIUM-ALBUTEROL | ipratropium/albuterol sulfate | AMPUL-NEB | 0.5 mg-3 mg (2.5 mg base)/3 mL | Y | Y | |
| 69097084064 | IPRATROPIUM-ALBUTEROL | ipratropium/albuterol sulfate | AMPUL-NEB | 0.5 mg-3 mg (2.5 mg base)/3 mL | Y | Y | |
| 69097084087 | IPRATROPIUM-ALBUTEROL | ipratropium/albuterol sulfate | AMPUL-NEB | 0.5 mg-3 mg (2.5 mg base)/3 mL | Y | Y | |
| 76204060001 | IPRATROPIUM-ALBUTEROL | ipratropium/albuterol sulfate | AMPUL-NEB | 0.5 mg-3 mg (2.5 mg base)/3 mL | Y | Y | |
| 76204060005 | IPRATROPIUM-ALBUTEROL | ipratropium/albuterol sulfate | AMPUL-NEB | 0.5 mg-3 mg (2.5 mg base)/3 mL | Y | Y | |
| 76204060012 | IPRATROPIUM-ALBUTEROL | ipratropium/albuterol sulfate | AMPUL-NEB | 0.5 mg-3 mg (2.5 mg base)/3 mL | Y | Y | |
| 76204060030 | IPRATROPIUM-ALBUTEROL | ipratropium/albuterol sulfate | AMPUL-NEB | 0.5 mg-3 mg (2.5 mg base)/3 mL | Y | Y | |
| 76204060060 | IPRATROPIUM-ALBUTEROL | ipratropium/albuterol sulfate | AMPUL-NEB | 0.5 mg-3 mg (2.5 mg base)/3 mL | Y | Y | |
| 00597002402 | COMBIVENT RESPIMAT | ipratropium/albuterol sulfate | MIST INHAL | 20 mcg-100 mcg/actuation | Y | Y | |
| 49502080632 | YUPELRI | revefenacin | VIAL-NEB | 175 mcg/3 mL | N | Y | |
| 49502080687 | YUPELRI | revefenacin | VIAL-NEB | 175 mcg/3 mL | N | Y | |
| 49502080693 | YUPELRI | revefenacin | VIAL-NEB | 175 mcg/3 mL | N | Y | |
| 00597007541 | SPIRIVA HANDIHALER | tiotropium bromide | CAP W/DEV | 18 mcg | N | Y | |
| 00597007547 | SPIRIVA HANDIHALER | tiotropium bromide | CAP W/DEV | 18 mcg | N | Y | |
| 00597007575 | SPIRIVA HANDIHALER | tiotropium bromide | CAP W/DEV | 18 mcg | N | Y | |
| 68180096411 | TIOTROPIUM BROMIDE | tiotropium bromide | CAP W/DEV | 18 mcg | N | Y | |
| 68180096412 | TIOTROPIUM BROMIDE | tiotropium bromide | CAP W/DEV | 18 mcg | N | Y | |
| 00597016061 | SPIRIVA RESPIMAT | tiotropium bromide | MIST INHAL | 1.25 mcg/actuation | Y | Y | |
| 00597010028 | SPIRIVA RESPIMAT | tiotropium bromide | MIST INHAL | 2.5 mcg/actuation | Y | Y | |
| 00597010051 | SPIRIVA RESPIMAT | tiotropium bromide | MIST INHAL | 2.5 mcg/actuation | Y | Y | |
| 00597010061 | SPIRIVA RESPIMAT | tiotropium bromide | MIST INHAL | 2.5 mcg/actuation | Y | Y | |
| 00173087306 | INCRUSE ELLIPTA | umeclidinium bromide | BLST W/DEV | 62.5 mcg/actuation | Y | Y | |
| 00173087310 | INCRUSE ELLIPTA | umeclidinium bromide | BLST W/DEV | 62.5 mcg/actuation | Y | Y |