Beta-Agonists, Inhaled Long Acting
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 | Carveout ‐ Bill FFS |
Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|---|
| 00093595506 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 00093595511 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 00093595519 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 00093595545 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 00093595556 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 42571046473 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | Y | N | ||
| 42571046475 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | Y | N | ||
| 43598077711 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 43598077730 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 43598077748 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 43598077760 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 50742039505 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 50742039530 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 50742039560 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 60687077079 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 60687077083 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 60687077084 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 62332063301 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 62332063304 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 62332063330 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 62332063360 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 62756027701 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 62756027702 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 62756027703 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 69097016832 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 69097016848 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 69097016853 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 69097016864 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 69097016887 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 70436015119 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 70436015120 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 70436015157 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 70436015158 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 70748017501 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 70748017530 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 70748017560 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 70756061212 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 70756061244 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 70756061260 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 70756061270 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 72266025901 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 72266025904 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 72266025930 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 72266025960 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 72603020801 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 72603020804 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 72603020830 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 72603020860 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 73043005201 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 73043005204 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 73043005260 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 73043005293 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 76204002601 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 76204002602 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 76204002611 | ARFORMOTEROL TARTRATE | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 27437005501 | BROVANA | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 27437005504 | BROVANA | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 27437005530 | BROVANA | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 27437005560 | BROVANA | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 27437006001 | BROVANA | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 27437006030 | BROVANA | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 27437006060 | BROVANA | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 63402091108 | BROVANA | arformoterol tartrate | VIAL-NEB | 15 mcg/2 mL | N | Y | N | Pharmacy PA |
| 00093406106 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 00093406119 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 00093406130 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 00378163132 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 00378163191 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 00378163193 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 00904745411 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 00904745414 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 00904745455 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 00904745498 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 42571046362 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 42571046373 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 42571046375 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 42858009421 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 42858009435 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 42858009462 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 43598077811 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 43598077830 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 43598077860 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 50742039401 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 50742039430 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 50742039460 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 62332065501 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 62332065530 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 62332065560 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 70748026101 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 70748026130 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 70748026160 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 70756060812 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 70756060860 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 70756060870 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 72603062001 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 72603062004 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 72603062030 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 72603062060 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 73043005101 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 73043005193 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 73043005196 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 73289006001 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 73289006002 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 73289006003 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 76204003001 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 76204003002 | FORMOTEROL FUMARATE | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 49502060530 | PERFOROMIST | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 49502060561 | PERFOROMIST | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 49502060595 | PERFOROMIST | formoterol fumarate | VIAL-NEB | 20 mcg/2 mL | N | Y | N | Pharmacy PA |
| 00597019261 | STRIVERDI RESPIMAT | olodaterol HCl | MIST INHAL | 2.5 mcg/actuation | N | Y | N | Pharmacy PA |
| 00173052100 | SEREVENT DISKUS | salmeterol xinafoate | BLST W/DEV | 50 mcg | Y | Y | N |