Miscellaneous Pulmonary Agents
PDL Reference Documents
- COPD Class Update - Dec 05, 2024
- Asthma and COPD maintenance medications - Oct 01, 2020
- Asthma Biologics - Jul 26, 2018
- Monoclonal Antibodies for Asthma - Jul 28, 2016
- Asthma and COPD - Sep 24, 2015
- COPD/Asthma Class Update - Jul 31, 2014
- COPD Class Update and Breo Ellipta New Drug Evaluation - Nov 21, 2013
- Class Scan: COPD Medications - Sep 26, 2013
- Drug Class Review: Controller Medications for Asthma - Jul 25, 2013
- Class Update: Asthma Controllers - May 31, 2012
- Abbreviated Class Review: COPD - Feb 23, 2012
Newsletters
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 |
---|---|---|---|---|---|---|---|
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 |