Beta-Agonists, Inhaled Short-Acting
PDL Reference Documents
- Inhalers for Asthma and COPD - Jun 06, 2024
- Inhalers for Asthma and COPD - Feb 01, 2024
- Inhalers for Asthma/COPD - Dec 01, 2022
- Short-Acting Beta Agonists - Jul 25, 2019
- Asthma and COPD - Sep 24, 2015
- COPD/Asthma Class Update - Jul 31, 2014
- Asthma Rescue DERP Scan - Mar 27, 2014
- Asthma Rescue Scan Summary - Mar 27, 2014
Drug Use Review Documents
Newsletters
- March 2024 - Asthma Relief Inhaler Drug Use Evaluation
- August 2023 - 2023 Global Initiative for Chronic Obstructive Lung Disease Report: Focus on Revised Recommendations for Inhaler Products
- April 2022 - Asthma Guidance Update with a Focus on Changes for Managing Patients with Mild Asthma
- May 2017 - Updates in the Management of Chronic Obstructive Pulmonary Disease
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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|
| 50111080132 | ALBUTEROL | albuterol | AER REFILL | 90 mcg | N | Y | |
| 59310058020 | PROAIR RESPICLICK | albuterol sulfate | AER POW BA | 90 mcg | N | Y | |
| 59310011720 | PROAIR DIGIHALER | albuterol sulfate | AER PW BAS | 90 mcg | N | Y | |
| 59310054020 | PROAIR DIGIHALER | albuterol sulfate | AER PW BAS | 90 mcg | N | Y | |
| 00054074287 | ALBUTEROL SULFATE HFA | albuterol sulfate | HFA AER AD | 90 mcg | Y | Y | |
| 00093317431 | ALBUTEROL SULFATE HFA | albuterol sulfate | HFA AER AD | 90 mcg | Y | Y | |
| 00781729685 | ALBUTEROL SULFATE HFA | albuterol sulfate | HFA AER AD | 90 mcg | Y | Y | |
| 17270074000 | ALBUTEROL SULFATE HFA | albuterol sulfate | HFA AER AD | 90 mcg | Y | Y | |
| 45802008801 | ALBUTEROL SULFATE HFA | albuterol sulfate | HFA AER AD | 90 mcg | Y | Y | |
| 60687066291 | ALBUTEROL SULFATE HFA | albuterol sulfate | HFA AER AD | 90 mcg | Y | Y | |
| 66993001968 | ALBUTEROL SULFATE HFA | albuterol sulfate | HFA AER AD | 90 mcg | Y | Y | |
| 68180096301 | ALBUTEROL SULFATE HFA | albuterol sulfate | HFA AER AD | 90 mcg | Y | Y | |
| 69097014260 | ALBUTEROL SULFATE HFA | albuterol sulfate | HFA AER AD | 90 mcg | Y | Y | |
| 72572001401 | ALBUTEROL SULFATE HFA | albuterol sulfate | HFA AER AD | 90 mcg | Y | Y | |
| 76282067942 | ALBUTEROL SULFATE HFA | albuterol sulfate | HFA AER AD | 90 mcg | Y | Y | |
| 00173068220 | VENTOLIN HFA | albuterol sulfate | HFA AER AD | 90 mcg | Y | Y | |
| 00173068224 | VENTOLIN HFA | albuterol sulfate | HFA AER AD | 90 mcg | Y | Y | |
| 00378705752 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 0.63 mg/3 mL | Y | Y | |
| 00378705798 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 0.63 mg/3 mL | Y | Y | |
| 00487030101 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 0.63 mg/3 mL | Y | Y | |
| 00591346753 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 0.63 mg/3 mL | Y | Y | |
| 50742039205 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 0.63 mg/3 mL | Y | Y | |
| 50742039225 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 0.63 mg/3 mL | Y | Y | |
| 59651018305 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 0.63 mg/3 mL | Y | Y | |
| 59651018325 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 0.63 mg/3 mL | Y | Y | |
| 59651018330 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 0.63 mg/3 mL | Y | Y | |
| 62135082684 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 0.63 mg/3 mL | Y | Y | |
| 76204001001 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 0.63 mg/3 mL | Y | Y | |
| 76204001005 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 0.63 mg/3 mL | Y | Y | |
| 76204001011 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 0.63 mg/3 mL | Y | Y | |
| 76204001055 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 0.63 mg/3 mL | Y | Y | |
| 00378705852 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 1.25 mg/3 mL | Y | Y | |
| 00378705898 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 1.25 mg/3 mL | Y | Y | |
| 00487990401 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 1.25 mg/3 mL | Y | Y | |
| 00487990425 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 1.25 mg/3 mL | Y | Y | |
| 00591346853 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 1.25 mg/3 mL | Y | Y | |
| 50742039305 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 1.25 mg/3 mL | Y | Y | |
| 50742039325 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 1.25 mg/3 mL | Y | Y | |
| 59651018405 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 1.25 mg/3 mL | Y | Y | |
| 59651018425 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 1.25 mg/3 mL | Y | Y | |
| 59651018430 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 1.25 mg/3 mL | Y | Y | |
| 62135082784 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 1.25 mg/3 mL | Y | Y | |
| 76204001101 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 1.25 mg/3 mL | Y | Y | |
| 76204001105 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 1.25 mg/3 mL | Y | Y | |
| 76204001111 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 1.25 mg/3 mL | Y | Y | |
| 76204001155 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 1.25 mg/3 mL | Y | Y | |
| 00487990130 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 2.5 mg/0.5 mL | Y | Y | |
| 62135082984 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 2.5 mg/0.5 mL | Y | Y | |
| 64980064203 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 2.5 mg/0.5 mL | Y | Y | |
| 76204002701 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 2.5 mg/0.5 mL | Y | Y | |
| 76204002711 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 2.5 mg/0.5 mL | Y | Y | |
| 00378827031 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 2.5 mg/3 mL (0.083 %) | Y | Y | |
| 00378827052 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 2.5 mg/3 mL (0.083 %) | Y | Y | |
| 00378827055 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 2.5 mg/3 mL (0.083 %) | Y | Y | |
| 00378827062 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 2.5 mg/3 mL (0.083 %) | Y | Y | |
| 00378827064 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 2.5 mg/3 mL (0.083 %) | Y | Y | |
| 00378827091 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 2.5 mg/3 mL (0.083 %) | Y | Y | |
| 00378827093 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 2.5 mg/3 mL (0.083 %) | Y | Y | |
| 00487950100 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 2.5 mg/3 mL (0.083 %) | Y | Y | |
| 00487950101 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 2.5 mg/3 mL (0.083 %) | Y | Y | |
| 00487950103 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 2.5 mg/3 mL (0.083 %) | Y | Y | |
| 00487950125 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 2.5 mg/3 mL (0.083 %) | Y | Y | |
| 00487950160 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 2.5 mg/3 mL (0.083 %) | Y | Y | |
| 47335070348 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 2.5 mg/3 mL (0.083 %) | Y | Y | |
| 47335070349 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 2.5 mg/3 mL (0.083 %) | Y | Y | |
| 47335070352 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 2.5 mg/3 mL (0.083 %) | Y | Y | |
| 47335070354 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 2.5 mg/3 mL (0.083 %) | Y | Y | |
| 60687039579 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 2.5 mg/3 mL (0.083 %) | Y | Y | |
| 60687039583 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 2.5 mg/3 mL (0.083 %) | Y | Y | |
| 62135082884 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 2.5 mg/3 mL (0.083 %) | Y | Y | |
| 65862085801 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 2.5 mg/3 mL (0.083 %) | Y | Y | |
| 65862085805 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 2.5 mg/3 mL (0.083 %) | Y | Y | |
| 65862085825 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 2.5 mg/3 mL (0.083 %) | Y | Y | |
| 65862085830 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 2.5 mg/3 mL (0.083 %) | Y | Y | |
| 65862085860 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 2.5 mg/3 mL (0.083 %) | Y | Y | |
| 76204020001 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 2.5 mg/3 mL (0.083 %) | Y | Y | |
| 76204020025 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 2.5 mg/3 mL (0.083 %) | Y | Y | |
| 76204020030 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 2.5 mg/3 mL (0.083 %) | Y | Y | |
| 76204020060 | ALBUTEROL SULFATE | albuterol sulfate | VIAL-NEB | 2.5 mg/3 mL (0.083 %) | Y | Y | |
| 00093414545 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 0.31 mg/3 mL | N | Y | |
| 00093414556 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 0.31 mg/3 mL | N | Y | |
| 00115993076 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 0.31 mg/3 mL | N | Y | |
| 00115993078 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 0.31 mg/3 mL | N | Y | |
| 00378969052 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 0.31 mg/3 mL | N | Y | |
| 00378969062 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 0.31 mg/3 mL | N | Y | |
| 35573044325 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 0.31 mg/3 mL | N | Y | |
| 47335074349 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 0.31 mg/3 mL | N | Y | |
| 76204070001 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 0.31 mg/3 mL | N | Y | |
| 76204070011 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 0.31 mg/3 mL | N | Y | |
| 76204070015 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 0.31 mg/3 mL | N | Y | |
| 76204070025 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 0.31 mg/3 mL | N | Y | |
| 00093414645 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 0.63 mg/3 mL | N | Y | |
| 00093414656 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 0.63 mg/3 mL | N | Y | |
| 00115993176 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 0.63 mg/3 mL | N | Y | |
| 00115993178 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 0.63 mg/3 mL | N | Y | |
| 00378969152 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 0.63 mg/3 mL | N | Y | |
| 00378969162 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 0.63 mg/3 mL | N | Y | |
| 35573044425 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 0.63 mg/3 mL | N | Y | |
| 47335074649 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 0.63 mg/3 mL | N | Y | |
| 76204080001 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 0.63 mg/3 mL | N | Y | |
| 76204080011 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 0.63 mg/3 mL | N | Y | |
| 76204080015 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 0.63 mg/3 mL | N | Y | |
| 76204080025 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 0.63 mg/3 mL | N | Y | |
| 00378699331 | LEVALBUTEROL CONCENTRATE | levalbuterol HCl | VIAL-NEB | 1.25 mg/0.5 mL | N | Y | |
| 00378699393 | LEVALBUTEROL CONCENTRATE | levalbuterol HCl | VIAL-NEB | 1.25 mg/0.5 mL | N | Y | |
| 65862094203 | LEVALBUTEROL CONCENTRATE | levalbuterol HCl | VIAL-NEB | 1.25 mg/0.5 mL | N | Y | |
| 65862094250 | LEVALBUTEROL CONCENTRATE | levalbuterol HCl | VIAL-NEB | 1.25 mg/0.5 mL | N | Y | |
| 00093414845 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 1.25 mg/3 mL | N | Y | |
| 00093414856 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 1.25 mg/3 mL | N | Y | |
| 00115993276 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 1.25 mg/3 mL | N | Y | |
| 00115993278 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 1.25 mg/3 mL | N | Y | |
| 00378969252 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 1.25 mg/3 mL | N | Y | |
| 00378969262 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 1.25 mg/3 mL | N | Y | |
| 35573044525 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 1.25 mg/3 mL | N | Y | |
| 47335075349 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 1.25 mg/3 mL | N | Y | |
| 76204090001 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 1.25 mg/3 mL | N | Y | |
| 76204090011 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 1.25 mg/3 mL | N | Y | |
| 76204090015 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 1.25 mg/3 mL | N | Y | |
| 76204090025 | LEVALBUTEROL HCL | levalbuterol HCl | VIAL-NEB | 1.25 mg/3 mL | N | Y | |
| 00591292754 | LEVALBUTEROL TARTRATE HFA | levalbuterol tartrate | HFA AER AD | 45 mcg/actuation | N | Y | |
| 27437005601 | XOPENEX HFA | levalbuterol tartrate | HFA AER AD | 45 mcg/actuation | N | Y |