Anticholinergics, 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 but eligible patients will encounter a co-pay at the pharmacy.
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.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
ipratropium bromide ATROVENT HFA HFA AER AD Y    
ipratropium bromide IPRATROPIUM BROMIDE SOLUTION Y    
ipratropium/albuterol sulfate IPRATROPIUM-ALBUTEROL AMPUL-NEB Y    
tiotropium bromide SPIRIVA CAP W/DEV Y    
aclidinium bromide TUDORZA PRESSAIR AER POW BA N   Jan 31, 2013
glycopyrrolate SEEBRI NEOHALER CAP W/DEV N   May 26, 2016
ipratropium/albuterol sulfate COMBIVENT RESPIMAT MIST INHAL N    
tiotropium bromide SPIRIVA RESPIMAT MIST INHAL N    
umeclidinium bromide INCRUSE ELLIPTA BLST W/DEV N