Corticosteroids/Beta-Agonist Combination, Inhaled
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
- Asthma and COPD maintenance medications - Oct 01, 2020
- Asthma and COPD Maintenance Medications - May 23, 2019
- Class Scan: Asthma and COPD - Jan 25, 2018
- Drugs to Treat Asthma and Chronic Obstructive Pulmonary Disease (COPD) - Sep 29, 2016
- Asthma and COPD - Sep 24, 2015
- COPD/Asthma Class Update - Jul 31, 2014
- COPD Class Update and Breo Ellipta New Drug Evaluation - Nov 21, 2013
- Class Scan: COPD Medications - Sep 26, 2013
- Drug Class Review: Controller Medications for Asthma - Jul 25, 2013
- Class Update: Asthma Controllers - May 31, 2012
- Abbreviated Class Review: COPD - Feb 23, 2012
Drug Use Review Documents
Newsletters
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 |
---|---|---|---|---|---|---|---|
00310908012 | AIRSUPRA | albuterol sulfate/budesonide | HFA AER AD | 90 mcg-80 mcg/actuation | N | Y | |
00310908028 | AIRSUPRA | albuterol sulfate/budesonide | HFA AER AD | 90 mcg-80 mcg/actuation | N | Y | |
00378750332 | BREYNA | budesonide/formoterol fumarate | HFA AER AD | 160 mcg-4.5 mcg/actuation | Y | Y | |
00310737020 | BUDESONIDE-FORMOTEROL FUMARATE | budesonide/formoterol fumarate | HFA AER AD | 160 mcg-4.5 mcg/actuation | Y | Y | |
00186037020 | SYMBICORT | budesonide/formoterol fumarate | HFA AER AD | 160 mcg-4.5 mcg/actuation | Y | Y | |
00186037028 | SYMBICORT | budesonide/formoterol fumarate | HFA AER AD | 160 mcg-4.5 mcg/actuation | Y | Y | |
00186037060 | SYMBICORT | budesonide/formoterol fumarate | HFA AER AD | 160 mcg-4.5 mcg/actuation | Y | Y | |
00378750232 | BREYNA | budesonide/formoterol fumarate | HFA AER AD | 80 mcg-4.5 mcg/actuation | Y | Y | |
00310737220 | BUDESONIDE-FORMOTEROL FUMARATE | budesonide/formoterol fumarate | HFA AER AD | 80 mcg-4.5 mcg/actuation | Y | Y | |
00186037220 | SYMBICORT | budesonide/formoterol fumarate | HFA AER AD | 80 mcg-4.5 mcg/actuation | Y | Y | |
00186037228 | SYMBICORT | budesonide/formoterol fumarate | HFA AER AD | 80 mcg-4.5 mcg/actuation | Y | Y | |
59310081206 | AIRDUO RESPICLICK | fluticasone propion/salmeterol | AER POW BA | 113 mcg-14 mcg/actuation | Y | Y | |
00093360882 | FLUTICASONE-SALMETEROL | fluticasone propion/salmeterol | AER POW BA | 113 mcg-14 mcg/actuation | Y | Y | |
59310082206 | AIRDUO RESPICLICK | fluticasone propion/salmeterol | AER POW BA | 232 mcg-14 mcg/actuation | Y | Y | |
00093360982 | FLUTICASONE-SALMETEROL | fluticasone propion/salmeterol | AER POW BA | 232 mcg-14 mcg/actuation | Y | Y | |
59310080506 | AIRDUO RESPICLICK | fluticasone propion/salmeterol | AER POW BA | 55 mcg-14 mcg/actuation | Y | Y | |
00093360782 | FLUTICASONE-SALMETEROL | fluticasone propion/salmeterol | AER POW BA | 55 mcg-14 mcg/actuation | Y | Y | |
59310052008 | AIRDUO DIGIHALER | fluticasone propion/salmeterol | AER PW BAS | 113 mcg-14 mcg/actuation | N | Y | |
59310053008 | AIRDUO DIGIHALER | fluticasone propion/salmeterol | AER PW BAS | 232 mcg-14 mcg/actuation | N | Y | |
00173069500 | ADVAIR DISKUS | fluticasone propion/salmeterol | BLST W/DEV | 100 mcg-50 mcg/dose | Y | Y | |
00173069504 | ADVAIR DISKUS | fluticasone propion/salmeterol | BLST W/DEV | 100 mcg-50 mcg/dose | Y | Y | |
00054032656 | FLUTICASONE-SALMETEROL | fluticasone propion/salmeterol | BLST W/DEV | 100 mcg-50 mcg/dose | Y | Y | |
00093751731 | FLUTICASONE-SALMETEROL | fluticasone propion/salmeterol | BLST W/DEV | 100 mcg-50 mcg/dose | Y | Y | |
66993058497 | FLUTICASONE-SALMETEROL | fluticasone propion/salmeterol | BLST W/DEV | 100 mcg-50 mcg/dose | Y | Y | |
00378932032 | WIXELA INHUB | fluticasone propion/salmeterol | BLST W/DEV | 100 mcg-50 mcg/dose | Y | Y | |
00173069600 | ADVAIR DISKUS | fluticasone propion/salmeterol | BLST W/DEV | 250 mcg-50 mcg/dose | Y | Y | |
00173069604 | ADVAIR DISKUS | fluticasone propion/salmeterol | BLST W/DEV | 250 mcg-50 mcg/dose | Y | Y | |
00054032756 | FLUTICASONE-SALMETEROL | fluticasone propion/salmeterol | BLST W/DEV | 250 mcg-50 mcg/dose | Y | Y | |
00093751831 | FLUTICASONE-SALMETEROL | fluticasone propion/salmeterol | BLST W/DEV | 250 mcg-50 mcg/dose | Y | Y | |
66993058597 | FLUTICASONE-SALMETEROL | fluticasone propion/salmeterol | BLST W/DEV | 250 mcg-50 mcg/dose | Y | Y | |
00378932132 | WIXELA INHUB | fluticasone propion/salmeterol | BLST W/DEV | 250 mcg-50 mcg/dose | Y | Y | |
00173069700 | ADVAIR DISKUS | fluticasone propion/salmeterol | BLST W/DEV | 500 mcg-50 mcg/dose | Y | Y | |
00173069704 | ADVAIR DISKUS | fluticasone propion/salmeterol | BLST W/DEV | 500 mcg-50 mcg/dose | Y | Y | |
00054032856 | FLUTICASONE-SALMETEROL | fluticasone propion/salmeterol | BLST W/DEV | 500 mcg-50 mcg/dose | Y | Y | |
00093751631 | FLUTICASONE-SALMETEROL | fluticasone propion/salmeterol | BLST W/DEV | 500 mcg-50 mcg/dose | Y | Y | |
66993058697 | FLUTICASONE-SALMETEROL | fluticasone propion/salmeterol | BLST W/DEV | 500 mcg-50 mcg/dose | Y | Y | |
00378932232 | WIXELA INHUB | fluticasone propion/salmeterol | BLST W/DEV | 500 mcg-50 mcg/dose | Y | Y | |
00173071620 | ADVAIR HFA | fluticasone propion/salmeterol | HFA AER AD | 115 mcg-21 mcg/actuation | Y | Y | |
00173071622 | ADVAIR HFA | fluticasone propion/salmeterol | HFA AER AD | 115 mcg-21 mcg/actuation | Y | Y | |
66993008796 | FLUTICASONE-SALMETEROL HFA | fluticasone propion/salmeterol | HFA AER AD | 115 mcg-21 mcg/actuation | Y | Y | |
00173071720 | ADVAIR HFA | fluticasone propion/salmeterol | HFA AER AD | 230 mcg-21 mcg/actuation | Y | Y | |
00173071722 | ADVAIR HFA | fluticasone propion/salmeterol | HFA AER AD | 230 mcg-21 mcg/actuation | Y | Y | |
66993008896 | FLUTICASONE-SALMETEROL HFA | fluticasone propion/salmeterol | HFA AER AD | 230 mcg-21 mcg/actuation | Y | Y | |
00173071520 | ADVAIR HFA | fluticasone propion/salmeterol | HFA AER AD | 45 mcg-21 mcg/actuation | Y | Y | |
00173071522 | ADVAIR HFA | fluticasone propion/salmeterol | HFA AER AD | 45 mcg-21 mcg/actuation | Y | Y | |
66993008696 | FLUTICASONE-SALMETEROL HFA | fluticasone propion/salmeterol | HFA AER AD | 45 mcg-21 mcg/actuation | Y | Y | |
00173085910 | BREO ELLIPTA | fluticasone/vilanterol | BLST W/DEV | 100 mcg-25 mcg/dose | N | Y | |
00173085914 | BREO ELLIPTA | fluticasone/vilanterol | BLST W/DEV | 100 mcg-25 mcg/dose | N | Y | |
66993013597 | FLUTICASONE-VILANTEROL | fluticasone/vilanterol | BLST W/DEV | 100 mcg-25 mcg/dose | N | Y | |
00173088210 | BREO ELLIPTA | fluticasone/vilanterol | BLST W/DEV | 200 mcg-25 mcg/dose | N | Y | |
00173088214 | BREO ELLIPTA | fluticasone/vilanterol | BLST W/DEV | 200 mcg-25 mcg/dose | N | Y | |
66993013697 | FLUTICASONE-VILANTEROL | fluticasone/vilanterol | BLST W/DEV | 200 mcg-25 mcg/dose | N | Y | |
00173091610 | BREO ELLIPTA | fluticasone/vilanterol | BLST W/DEV | 50 mcg-25 mcg/dose | N | Y | |
78206012701 | DULERA | mometasone/formoterol | HFA AER AD | 100 mcg-5 mcg/actuation | Y | Y | |
78206012702 | DULERA | mometasone/formoterol | HFA AER AD | 100 mcg-5 mcg/actuation | Y | Y | |
78206012601 | DULERA | mometasone/formoterol | HFA AER AD | 200 mcg-5 mcg/actuation | Y | Y | |
78206012602 | DULERA | mometasone/formoterol | HFA AER AD | 200 mcg-5 mcg/actuation | Y | Y | |
78206012659 | DULERA | mometasone/formoterol | HFA AER AD | 200 mcg-5 mcg/actuation | Y | Y | |
78206012501 | DULERA | mometasone/formoterol | HFA AER AD | 50 mcg-5 mcg/actuation | Y | Y |