LAMA/LABA Combination, Inhalers
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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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Carveout ‐ Bill FFS |
Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|---|
| 70515000101 | DUAKLIR PRESSAIR | aclidinium brom/formoterol fum | AER POW BA | 400 mcg-12 mcg/actuation | N | Y | N | Pharmacy PA |
| 00310461612 | BREZTRI AEROSPHERE | budesonide/glycopyr/formoterol | HFA AER AD | 160 mcg-9 mcg-4.8 mcg/actuation | N | Y | N | Pharmacy PA |
| 00310461628 | BREZTRI AEROSPHERE | budesonide/glycopyr/formoterol | HFA AER AD | 160 mcg-9 mcg-4.8 mcg/actuation | N | Y | N | Pharmacy PA |
| 00310461639 | BREZTRI AEROSPHERE | budesonide/glycopyr/formoterol | HFA AER AD | 160 mcg-9 mcg-4.8 mcg/actuation | N | Y | N | Pharmacy PA |
| 00173088710 | TRELEGY ELLIPTA | fluticasone/umeclidin/vilanter | BLST W/DEV | 100 mcg-62.5 mcg-25 mcg/actuation | N | Y | N | Pharmacy PA |
| 00173088714 | TRELEGY ELLIPTA | fluticasone/umeclidin/vilanter | BLST W/DEV | 100 mcg-62.5 mcg-25 mcg/actuation | N | Y | N | Pharmacy PA |
| 00173088761 | TRELEGY ELLIPTA | fluticasone/umeclidin/vilanter | BLST W/DEV | 100 mcg-62.5 mcg-25 mcg/actuation | N | Y | N | Pharmacy PA |
| 00173089310 | TRELEGY ELLIPTA | fluticasone/umeclidin/vilanter | BLST W/DEV | 200 mcg-62.5 mcg-25 mcg/actuation | N | Y | N | Pharmacy PA |
| 00173089314 | TRELEGY ELLIPTA | fluticasone/umeclidin/vilanter | BLST W/DEV | 200 mcg-62.5 mcg-25 mcg/actuation | N | Y | N | Pharmacy PA |
| 00173089361 | TRELEGY ELLIPTA | fluticasone/umeclidin/vilanter | BLST W/DEV | 200 mcg-62.5 mcg-25 mcg/actuation | N | Y | N | Pharmacy PA |
| 00310460012 | BEVESPI AEROSPHERE | glycopyrrolate/formoterol fum | HFA AER AD | 9 mcg-4.8 mcg | N | Y | N | Pharmacy PA |
| 00597015561 | STIOLTO RESPIMAT | tiotropium Br/olodaterol HCl | MIST INHAL | 2.5 mcg-2.5 mcg/actuation | Y | Y | N | |
| 00597015570 | STIOLTO RESPIMAT | tiotropium Br/olodaterol HCl | MIST INHAL | 2.5 mcg-2.5 mcg/actuation | Y | Y | N | |
| 00173086906 | ANORO ELLIPTA | umeclidinium brm/vilanterol tr | BLST W/DEV | 62.5 mcg-25 mcg/actuation | Y | Y | N | |
| 00173086910 | ANORO ELLIPTA | umeclidinium brm/vilanterol tr | BLST W/DEV | 62.5 mcg-25 mcg/actuation | Y | Y | N | |
| 66993013497 | UMECLIDINIUM-VILANTEROL | umeclidinium brm/vilanterol tr | BLST W/DEV | 62.5 mcg-25 mcg/actuation | Y | Y | N |