Anticholinergics, Inhaled

← Back to Class List

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
IPRATROPIUM/ALBUTEROL SULFATE COMBIVENT RESPIMAT MIST INHAL N    
TIOTROPIUM BROMIDE SPIRIVA RESPIMAT MIST INHAL N    
UMECLIDINIUM BROMIDE INCRUSE ELLIPTA BLST W/DEV N