Beta-Agonists, Inhaled Long Acting

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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
SALMETEROL XINAFOATE SEREVENT DISKUS BLST W/DEV Y    
ARFORMOTEROL TARTRATE BROVANA VIAL-NEB N PA Document  
FORMOTEROL FUMARATE PERFOROMIST VIAL-NEB N PA Document  
INDACATEROL MALEATE ARCAPTA NEOHALER CAP W/DEV N PA Document Feb 23, 2012
OLODATEROL HCL STRIVERDI RESPIMAT MIST INHAL N PA Document Jan 29, 2015