Bronchial Dilators, Misc

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