Bronchial Dilators, Misc
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 |
|---|---|---|---|---|---|---|---|
| 62135018905 | ALBUTEROL SULFATE | albuterol sulfate | SYRUP | 2 mg/5 mL | Y | ||
| 62135018920 | ALBUTEROL SULFATE | albuterol sulfate | SYRUP | 2 mg/5 mL | Y | ||
| 62135018923 | ALBUTEROL SULFATE | albuterol sulfate | SYRUP | 2 mg/5 mL | Y | ||
| 62135018924 | ALBUTEROL SULFATE | albuterol sulfate | SYRUP | 2 mg/5 mL | Y | ||
| 62135018941 | ALBUTEROL SULFATE | albuterol sulfate | SYRUP | 2 mg/5 mL | Y | ||
| 62135018947 | ALBUTEROL SULFATE | albuterol sulfate | SYRUP | 2 mg/5 mL | Y | ||
| 70752010212 | ALBUTEROL SULFATE | albuterol sulfate | SYRUP | 2 mg/5 mL | Y | ||
| 53489017601 | ALBUTEROL SULFATE | albuterol sulfate | TABLET | 2 mg | Y | ||
| 62135067190 | ALBUTEROL SULFATE | albuterol sulfate | TABLET | 2 mg | Y | ||
| 64980044201 | ALBUTEROL SULFATE | albuterol sulfate | TABLET | 2 mg | Y | ||
| 68084094925 | ALBUTEROL SULFATE | albuterol sulfate | TABLET | 2 mg | Y | ||
| 68084094995 | ALBUTEROL SULFATE | albuterol sulfate | TABLET | 2 mg | Y | ||
| 69238134401 | ALBUTEROL SULFATE | albuterol sulfate | TABLET | 2 mg | Y | ||
| 70710106101 | ALBUTEROL SULFATE | albuterol sulfate | TABLET | 2 mg | Y | ||
| 53489017701 | ALBUTEROL SULFATE | albuterol sulfate | TABLET | 4 mg | Y | ||
| 62135067290 | ALBUTEROL SULFATE | albuterol sulfate | TABLET | 4 mg | Y | ||
| 64980044301 | ALBUTEROL SULFATE | albuterol sulfate | TABLET | 4 mg | Y | ||
| 69238134501 | ALBUTEROL SULFATE | albuterol sulfate | TABLET | 4 mg | Y | ||
| 70710106201 | ALBUTEROL SULFATE | albuterol sulfate | TABLET | 4 mg | Y | ||
| 00172640605 | CROMOLYN SODIUM | cromolyn sodium | AMPUL-NEB | 20 mg/2 mL | Y | ||
| 00172640649 | CROMOLYN SODIUM | cromolyn sodium | AMPUL-NEB | 20 mg/2 mL | Y | ||
| 24208037360 | CROMOLYN SODIUM | cromolyn sodium | AMPUL-NEB | 20 mg/2 mL | Y | ||
| 24208037362 | CROMOLYN SODIUM | cromolyn sodium | AMPUL-NEB | 20 mg/2 mL | Y | ||
| 42571035008 | CROMOLYN SODIUM | cromolyn sodium | AMPUL-NEB | 20 mg/2 mL | Y | ||
| 42571035009 | CROMOLYN SODIUM | cromolyn sodium | AMPUL-NEB | 20 mg/2 mL | Y | ||
| 69543045612 | CROMOLYN SODIUM | cromolyn sodium | AMPUL-NEB | 20 mg/2 mL | Y | ||
| 69543045660 | CROMOLYN SODIUM | cromolyn sodium | AMPUL-NEB | 20 mg/2 mL | Y | ||
| 76204002812 | CROMOLYN SODIUM | cromolyn sodium | AMPUL-NEB | 20 mg/2 mL | Y | ||
| 76204002860 | CROMOLYN SODIUM | cromolyn sodium | AMPUL-NEB | 20 mg/2 mL | Y | ||
| 17270055300 | PRIMATENE MIST | epinephrine | HFA AER AD | 0.125 mg/actuation | Y | ||
| 70644021530 | FORMOTEROL FUMARATE-NEBULIZER | formoterol fumarate/nebulizer | VIAL-NEB | 20 mcg/2 mL | Y | ||
| 70644021560 | FORMOTEROL FUMARATE-NEBULIZER | formoterol fumarate/nebulizer | VIAL-NEB | 20 mcg/2 mL | Y | ||
| 00281112453 | DILOR-G | guaifenesin/dyphylline | TABLET | 200 mg-200 mg | Y | ||
| 00281112457 | DILOR-G | guaifenesin/dyphylline | TABLET | 200 mg-200 mg | Y | ||
| 00281112463 | DILOR-G | guaifenesin/dyphylline | TABLET | 200 mg-200 mg | Y | ||
| 54092006710 | QUIBRON | guaifenesin/theophylline | CAPSULE | 90 mg-150 mg | Y | ||
| 61570002256 | QUIBRON | guaifenesin/theophylline | CAPSULE | 90 mg-150 mg | Y | ||
| 00054340840 | ISOETHARINE HCL | isoetharine HCl | SOLUTION | 10 mg/mL | Y | ||
| 00487590199 | S2 RACEPINEPHRINE | racepinephrine HCl | VIAL-NEB | 2.25 % | Y | ||
| 00115261101 | TERBUTALINE SULFATE | terbutaline sulfate | TABLET | 2.5 mg | Y | ||
| 00527131801 | TERBUTALINE SULFATE | terbutaline sulfate | TABLET | 2.5 mg | Y | ||
| 24979013201 | TERBUTALINE SULFATE | terbutaline sulfate | TABLET | 2.5 mg | Y | ||
| 62135052490 | TERBUTALINE SULFATE | terbutaline sulfate | TABLET | 2.5 mg | Y | ||
| 62559072101 | TERBUTALINE SULFATE | terbutaline sulfate | TABLET | 2.5 mg | Y | ||
| 00115262201 | TERBUTALINE SULFATE | terbutaline sulfate | TABLET | 5 mg | Y | ||
| 00527131101 | TERBUTALINE SULFATE | terbutaline sulfate | TABLET | 5 mg | Y | ||
| 24979013301 | TERBUTALINE SULFATE | terbutaline sulfate | TABLET | 5 mg | Y | ||
| 62135052590 | TERBUTALINE SULFATE | terbutaline sulfate | TABLET | 5 mg | Y | ||
| 62559072201 | TERBUTALINE SULFATE | terbutaline sulfate | TABLET | 5 mg | Y | ||
| 00143937501 | TERBUTALINE SULFATE | terbutaline sulfate | VIAL | 1 mg/mL | Y | ||
| 00143937510 | TERBUTALINE SULFATE | terbutaline sulfate | VIAL | 1 mg/mL | Y | ||
| 00143974601 | TERBUTALINE SULFATE | terbutaline sulfate | VIAL | 1 mg/mL | Y | ||
| 00143974610 | TERBUTALINE SULFATE | terbutaline sulfate | VIAL | 1 mg/mL | Y | ||
| 59923061501 | TERBUTALINE SULFATE | terbutaline sulfate | VIAL | 1 mg/mL | Y | ||
| 59923061505 | TERBUTALINE SULFATE | terbutaline sulfate | VIAL | 1 mg/mL | Y | ||
| 63323066500 | TERBUTALINE SULFATE | terbutaline sulfate | VIAL | 1 mg/mL | Y | ||
| 63323066501 | TERBUTALINE SULFATE | terbutaline sulfate | VIAL | 1 mg/mL | Y |