Corticosteroids/Beta-Agonist Combination, Inhaled

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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 Carveout
‐ Bill FFS		 Current Drug Use Criteria
00310908012 AIRSUPRA albuterol sulfate/budesonide HFA AER AD 90 mcg-80 mcg/actuation N Y N  
00310908028 AIRSUPRA albuterol sulfate/budesonide HFA AER AD 90 mcg-80 mcg/actuation N Y N  
00378750332 BREYNA budesonide/formoterol fumarate HFA AER AD 160 mcg-4.5 mcg/actuation Y Y N  
00310737020 BUDESONIDE-FORMOTEROL FUMARATE budesonide/formoterol fumarate HFA AER AD 160 mcg-4.5 mcg/actuation Y Y N  
00186037020 SYMBICORT budesonide/formoterol fumarate HFA AER AD 160 mcg-4.5 mcg/actuation Y Y N  
00186037028 SYMBICORT budesonide/formoterol fumarate HFA AER AD 160 mcg-4.5 mcg/actuation Y Y N  
00186037060 SYMBICORT budesonide/formoterol fumarate HFA AER AD 160 mcg-4.5 mcg/actuation Y Y N  
00378750232 BREYNA budesonide/formoterol fumarate HFA AER AD 80 mcg-4.5 mcg/actuation Y Y N  
00310737220 BUDESONIDE-FORMOTEROL FUMARATE budesonide/formoterol fumarate HFA AER AD 80 mcg-4.5 mcg/actuation Y Y N  
00186037220 SYMBICORT budesonide/formoterol fumarate HFA AER AD 80 mcg-4.5 mcg/actuation Y Y N  
00186037228 SYMBICORT budesonide/formoterol fumarate HFA AER AD 80 mcg-4.5 mcg/actuation Y Y N  
59310081206 AIRDUO RESPICLICK fluticasone propion/salmeterol AER POW BA 113 mcg-14 mcg/actuation Y Y N  
00093360882 FLUTICASONE-SALMETEROL fluticasone propion/salmeterol AER POW BA 113 mcg-14 mcg/actuation Y Y N  
59310082206 AIRDUO RESPICLICK fluticasone propion/salmeterol AER POW BA 232 mcg-14 mcg/actuation Y Y N  
00093360982 FLUTICASONE-SALMETEROL fluticasone propion/salmeterol AER POW BA 232 mcg-14 mcg/actuation Y Y N  
59310080506 AIRDUO RESPICLICK fluticasone propion/salmeterol AER POW BA 55 mcg-14 mcg/actuation Y Y N  
00093360782 FLUTICASONE-SALMETEROL fluticasone propion/salmeterol AER POW BA 55 mcg-14 mcg/actuation Y Y N  
59310052008 AIRDUO DIGIHALER fluticasone propion/salmeterol AER PW BAS 113 mcg-14 mcg/actuation N Y N  
59310053008 AIRDUO DIGIHALER fluticasone propion/salmeterol AER PW BAS 232 mcg-14 mcg/actuation N Y N  
00173069500 ADVAIR DISKUS fluticasone propion/salmeterol BLST W/DEV 100 mcg-50 mcg/dose Y Y N  
00173069504 ADVAIR DISKUS fluticasone propion/salmeterol BLST W/DEV 100 mcg-50 mcg/dose Y Y N  
00054032656 FLUTICASONE-SALMETEROL fluticasone propion/salmeterol BLST W/DEV 100 mcg-50 mcg/dose Y Y N  
00093751731 FLUTICASONE-SALMETEROL fluticasone propion/salmeterol BLST W/DEV 100 mcg-50 mcg/dose Y Y N  
66993058497 FLUTICASONE-SALMETEROL fluticasone propion/salmeterol BLST W/DEV 100 mcg-50 mcg/dose Y Y N  
00378932032 WIXELA INHUB fluticasone propion/salmeterol BLST W/DEV 100 mcg-50 mcg/dose Y Y N  
00173069600 ADVAIR DISKUS fluticasone propion/salmeterol BLST W/DEV 250 mcg-50 mcg/dose Y Y N  
00173069604 ADVAIR DISKUS fluticasone propion/salmeterol BLST W/DEV 250 mcg-50 mcg/dose Y Y N  
00054032756 FLUTICASONE-SALMETEROL fluticasone propion/salmeterol BLST W/DEV 250 mcg-50 mcg/dose Y Y N  
00093751831 FLUTICASONE-SALMETEROL fluticasone propion/salmeterol BLST W/DEV 250 mcg-50 mcg/dose Y Y N  
66993058597 FLUTICASONE-SALMETEROL fluticasone propion/salmeterol BLST W/DEV 250 mcg-50 mcg/dose Y Y N  
00378932132 WIXELA INHUB fluticasone propion/salmeterol BLST W/DEV 250 mcg-50 mcg/dose Y Y N  
00173069700 ADVAIR DISKUS fluticasone propion/salmeterol BLST W/DEV 500 mcg-50 mcg/dose Y Y N  
00173069704 ADVAIR DISKUS fluticasone propion/salmeterol BLST W/DEV 500 mcg-50 mcg/dose Y Y N  
00054032856 FLUTICASONE-SALMETEROL fluticasone propion/salmeterol BLST W/DEV 500 mcg-50 mcg/dose Y Y N  
00093751631 FLUTICASONE-SALMETEROL fluticasone propion/salmeterol BLST W/DEV 500 mcg-50 mcg/dose Y Y N  
66993058697 FLUTICASONE-SALMETEROL fluticasone propion/salmeterol BLST W/DEV 500 mcg-50 mcg/dose Y Y N  
00378932232 WIXELA INHUB fluticasone propion/salmeterol BLST W/DEV 500 mcg-50 mcg/dose Y Y N  
00173071620 ADVAIR HFA fluticasone propion/salmeterol HFA AER AD 115 mcg-21 mcg/actuation Y Y N  
00173071622 ADVAIR HFA fluticasone propion/salmeterol HFA AER AD 115 mcg-21 mcg/actuation Y Y N  
66993008796 FLUTICASONE-SALMETEROL HFA fluticasone propion/salmeterol HFA AER AD 115 mcg-21 mcg/actuation Y Y N  
00173071720 ADVAIR HFA fluticasone propion/salmeterol HFA AER AD 230 mcg-21 mcg/actuation Y Y N  
00173071722 ADVAIR HFA fluticasone propion/salmeterol HFA AER AD 230 mcg-21 mcg/actuation Y Y N  
66993008896 FLUTICASONE-SALMETEROL HFA fluticasone propion/salmeterol HFA AER AD 230 mcg-21 mcg/actuation Y Y N  
00173071520 ADVAIR HFA fluticasone propion/salmeterol HFA AER AD 45 mcg-21 mcg/actuation Y Y N  
00173071522 ADVAIR HFA fluticasone propion/salmeterol HFA AER AD 45 mcg-21 mcg/actuation Y Y N  
66993008696 FLUTICASONE-SALMETEROL HFA fluticasone propion/salmeterol HFA AER AD 45 mcg-21 mcg/actuation Y Y N  
00173085910 BREO ELLIPTA fluticasone/vilanterol BLST W/DEV 100 mcg-25 mcg/dose N Y N  
00173085914 BREO ELLIPTA fluticasone/vilanterol BLST W/DEV 100 mcg-25 mcg/dose N Y N  
66993013597 FLUTICASONE-VILANTEROL fluticasone/vilanterol BLST W/DEV 100 mcg-25 mcg/dose N Y N  
00173088210 BREO ELLIPTA fluticasone/vilanterol BLST W/DEV 200 mcg-25 mcg/dose N Y N  
00173088214 BREO ELLIPTA fluticasone/vilanterol BLST W/DEV 200 mcg-25 mcg/dose N Y N  
66993013697 FLUTICASONE-VILANTEROL fluticasone/vilanterol BLST W/DEV 200 mcg-25 mcg/dose N Y N  
00173091610 BREO ELLIPTA fluticasone/vilanterol BLST W/DEV 50 mcg-25 mcg/dose N Y N  
78206012701 DULERA mometasone/formoterol HFA AER AD 100 mcg-5 mcg/actuation Y Y N  
78206012702 DULERA mometasone/formoterol HFA AER AD 100 mcg-5 mcg/actuation Y Y N  
78206012601 DULERA mometasone/formoterol HFA AER AD 200 mcg-5 mcg/actuation Y Y N  
78206012602 DULERA mometasone/formoterol HFA AER AD 200 mcg-5 mcg/actuation Y Y N  
78206012659 DULERA mometasone/formoterol HFA AER AD 200 mcg-5 mcg/actuation Y Y N  
78206012501 DULERA mometasone/formoterol HFA AER AD 50 mcg-5 mcg/actuation Y Y N  
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