Beta-Agonists, Inhaled Long 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 Current Drug Use Criteria
00093595506 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
00093595511 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
00093595519 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
00093595545 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
00093595556 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
43598077711 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
43598077730 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
43598077748 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
43598077760 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
50742039505 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
50742039530 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
50742039560 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
60687077079 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
60687077083 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
60687077084 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
62332063301 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
62332063304 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
62332063330 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
62332063360 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
62756027701 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
62756027702 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
62756027703 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
69097016832 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
69097016848 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
69097016853 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
69097016864 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
69097016887 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
70436015119 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
70436015120 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
70436015157 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
70436015158 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
70748017501 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
70748017530 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
70748017560 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
70756061212 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
70756061244 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
70756061260 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
70756061270 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
72266025901 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
72266025904 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
72266025930 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
72266025960 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
72603020801 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
72603020804 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
72603020830 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
72603020860 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
73043005201 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
73043005204 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
73043005260 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
73043005293 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
76204002601 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
76204002602 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
76204002611 ARFORMOTEROL TARTRATE arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
27437005501 BROVANA arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
27437005504 BROVANA arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
27437005530 BROVANA arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
27437005560 BROVANA arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
27437006001 BROVANA arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
27437006030 BROVANA arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
27437006060 BROVANA arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
63402091108 BROVANA arformoterol tartrate VIAL-NEB 15 mcg/2 mL N Y PA Document
00093406106 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
00093406119 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
00093406130 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
00378163132 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
00378163191 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
00378163193 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
00904745411 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
00904745414 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
00904745455 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
00904745498 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
42571046362 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
42571046373 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
42571046375 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
42858009421 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
42858009435 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
42858009462 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
43598077811 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
43598077830 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
43598077860 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
50742039401 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
50742039430 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
50742039460 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
62332065501 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
62332065530 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
62332065560 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
70748026101 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
70748026130 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
70748026160 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
70756060812 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
70756060860 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
70756060870 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
72603062001 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
72603062004 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
72603062030 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
72603062060 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
73289006001 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
73289006002 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
73289006003 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
76204003001 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
76204003002 FORMOTEROL FUMARATE formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
49502060530 PERFOROMIST formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
49502060561 PERFOROMIST formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
49502060595 PERFOROMIST formoterol fumarate VIAL-NEB 20 mcg/2 mL N Y PA Document
00597019261 STRIVERDI RESPIMAT olodaterol HCl MIST INHAL 2.5 mcg/actuation N Y PA Document
00173052100 SEREVENT DISKUS salmeterol xinafoate BLST W/DEV 50 mcg Y Y  
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