Miscellaneous Pulmonary Agents

← 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
MONTELUKAST SODIUM SINGULAIR TAB CHEW Y    
MONTELUKAST SODIUM MONTELUKAST SODIUM TAB CHEW Y    
MONTELUKAST SODIUM SINGULAIR TABLET Y    
MONTELUKAST SODIUM MONTELUKAST SODIUM TABLET Y    
MEPOLIZUMAB NUCALA VIAL N PA Document  
MONTELUKAST SODIUM MONTELUKAST SODIUM GRAN PACK N    
MONTELUKAST SODIUM SINGULAIR GRAN PACK N    
OMALIZUMAB XOLAIR VIAL N PA Document  
RESLIZUMAB CINQAIR VIAL N PA Document  
ROFLUMILAST DALIRESP TABLET N PA Document Feb 23, 2012
ZAFIRLUKAST ACCOLATE TABLET N    
ZAFIRLUKAST ZAFIRLUKAST TABLET N    
ZILEUTON ZYFLO TABLET N    
ZILEUTON ZILEUTON ER TBMP 12HR N    
ZILEUTON ZYFLO CR TBMP 12HR N    
THEOPHYLLINE ANHYDROUS THEO-24 CAP ER 24H    
THEOPHYLLINE ANHYDROUS ELIXOPHYLLIN ELIXIR    
THEOPHYLLINE ANHYDROUS THEOPHYLLINE SOLUTION    
THEOPHYLLINE ANHYDROUS THEOPHYLLINE ANHYDROUS TAB ER 12H    
THEOPHYLLINE ANHYDROUS THEOPHYLLINE TAB ER 24H