Miscellaneous Pulmonary Agents

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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 Current Drug Use Criteria
83034000301 OHTUVAYRE ensifentrine AMPUL-NEB 3 mg/2.5 mL N Y PA Document
83034000360 OHTUVAYRE ensifentrine AMPUL-NEB 3 mg/2.5 mL N Y PA Document
13668053111 MONTELUKAST SODIUM montelukast sodium GRAN PACK 4 mg N Y  
13668053194 MONTELUKAST SODIUM montelukast sodium GRAN PACK 4 mg N Y  
27241001531 MONTELUKAST SODIUM montelukast sodium GRAN PACK 4 mg N Y  
55111076303 MONTELUKAST SODIUM montelukast sodium GRAN PACK 4 mg N Y  
55111076307 MONTELUKAST SODIUM montelukast sodium GRAN PACK 4 mg N Y  
59651032930 MONTELUKAST SODIUM montelukast sodium GRAN PACK 4 mg N Y  
78206017101 SINGULAIR montelukast sodium GRAN PACK 4 mg N Y  
13668007905 MONTELUKAST SODIUM montelukast sodium TAB CHEW 4 mg Y Y  
13668007930 MONTELUKAST SODIUM montelukast sodium TAB CHEW 4 mg Y Y  
13668007990 MONTELUKAST SODIUM montelukast sodium TAB CHEW 4 mg Y Y  
29300022110 MONTELUKAST SODIUM montelukast sodium TAB CHEW 4 mg Y Y  
29300022113 MONTELUKAST SODIUM montelukast sodium TAB CHEW 4 mg Y Y  
29300022119 MONTELUKAST SODIUM montelukast sodium TAB CHEW 4 mg Y Y  
31722072730 MONTELUKAST SODIUM montelukast sodium TAB CHEW 4 mg Y Y  
31722072790 MONTELUKAST SODIUM montelukast sodium TAB CHEW 4 mg Y Y  
33342011007 MONTELUKAST SODIUM montelukast sodium TAB CHEW 4 mg Y Y  
33342011010 MONTELUKAST SODIUM montelukast sodium TAB CHEW 4 mg Y Y  
50268057311 MONTELUKAST SODIUM montelukast sodium TAB CHEW 4 mg Y Y  
50268057315 MONTELUKAST SODIUM montelukast sodium TAB CHEW 4 mg Y Y  
57237021230 MONTELUKAST SODIUM montelukast sodium TAB CHEW 4 mg Y Y  
57237021290 MONTELUKAST SODIUM montelukast sodium TAB CHEW 4 mg Y Y  
62135078130 MONTELUKAST SODIUM montelukast sodium TAB CHEW 4 mg Y Y  
62175020443 MONTELUKAST SODIUM montelukast sodium TAB CHEW 4 mg Y Y  
65862056790 MONTELUKAST SODIUM montelukast sodium TAB CHEW 4 mg Y Y  
69452010619 MONTELUKAST SODIUM montelukast sodium TAB CHEW 4 mg Y Y  
78206017001 SINGULAIR montelukast sodium TAB CHEW 4 mg Y Y  
13668008005 MONTELUKAST SODIUM montelukast sodium TAB CHEW 5 mg Y Y  
13668008030 MONTELUKAST SODIUM montelukast sodium TAB CHEW 5 mg Y Y  
13668008090 MONTELUKAST SODIUM montelukast sodium TAB CHEW 5 mg Y Y  
29300022210 MONTELUKAST SODIUM montelukast sodium TAB CHEW 5 mg Y Y  
29300022213 MONTELUKAST SODIUM montelukast sodium TAB CHEW 5 mg Y Y  
29300022219 MONTELUKAST SODIUM montelukast sodium TAB CHEW 5 mg Y Y  
31722072830 MONTELUKAST SODIUM montelukast sodium TAB CHEW 5 mg Y Y  
31722072890 MONTELUKAST SODIUM montelukast sodium TAB CHEW 5 mg Y Y  
33342011107 MONTELUKAST SODIUM montelukast sodium TAB CHEW 5 mg Y Y  
33342011110 MONTELUKAST SODIUM montelukast sodium TAB CHEW 5 mg Y Y  
50268057411 MONTELUKAST SODIUM montelukast sodium TAB CHEW 5 mg Y Y  
50268057415 MONTELUKAST SODIUM montelukast sodium TAB CHEW 5 mg Y Y  
57237021330 MONTELUKAST SODIUM montelukast sodium TAB CHEW 5 mg Y Y  
57237021390 MONTELUKAST SODIUM montelukast sodium TAB CHEW 5 mg Y Y  
62135078230 MONTELUKAST SODIUM montelukast sodium TAB CHEW 5 mg Y Y  
62175020532 MONTELUKAST SODIUM montelukast sodium TAB CHEW 5 mg Y Y  
62175020543 MONTELUKAST SODIUM montelukast sodium TAB CHEW 5 mg Y Y  
65862056890 MONTELUKAST SODIUM montelukast sodium TAB CHEW 5 mg Y Y  
69452010713 MONTELUKAST SODIUM montelukast sodium TAB CHEW 5 mg Y Y  
69452010719 MONTELUKAST SODIUM montelukast sodium TAB CHEW 5 mg Y Y  
78206017301 SINGULAIR montelukast sodium TAB CHEW 5 mg Y Y  
00904680806 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
00904680861 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
13668008105 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
13668008130 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
13668008190 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
16571010009 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
16571010010 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
16729011910 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
16729011917 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
29300022010 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
29300022013 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
29300022019 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
31722072610 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
31722072630 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
31722072690 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
33342010207 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
33342010210 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
33342010215 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
50268055611 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
50268055615 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
55111072510 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
55111072530 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
55111072590 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
55111072594 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
65862057490 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
68001036103 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
68001036104 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
68001036105 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
68084087501 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
68084087511 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
68645056054 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
69367028705 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
69367028709 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
82009000910 MONTELUKAST SODIUM montelukast sodium TABLET 10 mg Y Y  
78206017201 SINGULAIR montelukast sodium TABLET 10 mg Y Y  
78206017202 SINGULAIR montelukast sodium TABLET 10 mg Y Y  
00310008828 DALIRESP roflumilast TABLET 250 mcg N Y PA Document
00310008839 DALIRESP roflumilast TABLET 250 mcg N Y PA Document
31722067631 ROFLUMILAST roflumilast TABLET 250 mcg N Y PA Document
31722067632 ROFLUMILAST roflumilast TABLET 250 mcg N Y PA Document
31722067635 ROFLUMILAST roflumilast TABLET 250 mcg N Y PA Document
31722067636 ROFLUMILAST roflumilast TABLET 250 mcg N Y PA Document
42571036983 ROFLUMILAST roflumilast TABLET 250 mcg N Y PA Document
67877073032 ROFLUMILAST roflumilast TABLET 250 mcg N Y PA Document
67877073093 ROFLUMILAST roflumilast TABLET 250 mcg N Y PA Document
68382062430 ROFLUMILAST roflumilast TABLET 250 mcg N Y PA Document
68382062431 ROFLUMILAST roflumilast TABLET 250 mcg N Y PA Document
68382062483 ROFLUMILAST roflumilast TABLET 250 mcg N Y PA Document
72205020111 ROFLUMILAST roflumilast TABLET 250 mcg N Y PA Document
72205020113 ROFLUMILAST roflumilast TABLET 250 mcg N Y PA Document
72205020124 ROFLUMILAST roflumilast TABLET 250 mcg N Y PA Document
72205020132 ROFLUMILAST roflumilast TABLET 250 mcg N Y PA Document
00310009530 DALIRESP roflumilast TABLET 500 mcg N Y PA Document
00310009590 DALIRESP roflumilast TABLET 500 mcg N Y PA Document
00378190577 ROFLUMILAST roflumilast TABLET 500 mcg N Y PA Document
00378190593 ROFLUMILAST roflumilast TABLET 500 mcg N Y PA Document
00904739946 ROFLUMILAST roflumilast TABLET 500 mcg N Y PA Document
00904739989 ROFLUMILAST roflumilast TABLET 500 mcg N Y PA Document
00904748303 ROFLUMILAST roflumilast TABLET 500 mcg N Y PA Document
00904748389 ROFLUMILAST roflumilast TABLET 500 mcg N Y PA Document
31722062330 ROFLUMILAST roflumilast TABLET 500 mcg N Y PA Document
31722062390 ROFLUMILAST roflumilast TABLET 500 mcg N Y PA Document
42571025930 ROFLUMILAST roflumilast TABLET 500 mcg N Y PA Document
43547000503 ROFLUMILAST roflumilast TABLET 500 mcg N Y PA Document
43547000509 ROFLUMILAST roflumilast TABLET 500 mcg N Y PA Document
59651027530 ROFLUMILAST roflumilast TABLET 500 mcg N Y PA Document
59651027590 ROFLUMILAST roflumilast TABLET 500 mcg N Y PA Document
60687078611 ROFLUMILAST roflumilast TABLET 500 mcg N Y PA Document
60687078621 ROFLUMILAST roflumilast TABLET 500 mcg N Y PA Document
67877048090 ROFLUMILAST roflumilast TABLET 500 mcg N Y PA Document
68382096906 ROFLUMILAST roflumilast TABLET 500 mcg N Y PA Document
68382096916 ROFLUMILAST roflumilast TABLET 500 mcg N Y PA Document
72205020030 ROFLUMILAST roflumilast TABLET 500 mcg N Y PA Document
72205020090 ROFLUMILAST roflumilast TABLET 500 mcg N Y PA Document
64380017701 ACCOLATE zafirlukast TABLET 10 mg N Y  
31722000760 ZAFIRLUKAST zafirlukast TABLET 10 mg N Y  
55111062560 ZAFIRLUKAST zafirlukast TABLET 10 mg N Y  
59651029160 ZAFIRLUKAST zafirlukast TABLET 10 mg N Y  
64380018701 ZAFIRLUKAST zafirlukast TABLET 10 mg N Y  
64380017801 ACCOLATE zafirlukast TABLET 20 mg N Y  
31722000860 ZAFIRLUKAST zafirlukast TABLET 20 mg N Y  
55111062660 ZAFIRLUKAST zafirlukast TABLET 20 mg N Y  
59651029260 ZAFIRLUKAST zafirlukast TABLET 20 mg N Y  
64380018801 ZAFIRLUKAST zafirlukast TABLET 20 mg N Y  
68084005911 ZAFIRLUKAST zafirlukast TABLET 20 mg N Y  
68084005921 ZAFIRLUKAST zafirlukast TABLET 20 mg N Y  
10122090112 ZYFLO zileuton TABLET 600 mg N Y  
31722004412 ZILEUTON ER zileuton TBMP 12HR 600 mg N Y  
64380018901 ZILEUTON ER zileuton TBMP 12HR 600 mg N Y  
64980020612 ZILEUTON ER zileuton TBMP 12HR 600 mg N Y  
68180016916 ZILEUTON ER zileuton TBMP 12HR 600 mg N Y  
72603024601 ZILEUTON ER zileuton TBMP 12HR 600 mg N Y