LAMA/LABA Combination, Inhalers

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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.
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.

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NDC Brand Name Generic Name Form Strength PDL
Status
Rebate Current Drug Use Criteria
70515000101 DUAKLIR PRESSAIR aclidinium brom/formoterol fum AER POW BA 400 mcg-12 mcg/actuation N Y PA Document
00310461612 BREZTRI AEROSPHERE budesonide/glycopyr/formoterol HFA AER AD 160 mcg-9 mcg-4.8 mcg/actuation N Y PA Document
00310461628 BREZTRI AEROSPHERE budesonide/glycopyr/formoterol HFA AER AD 160 mcg-9 mcg-4.8 mcg/actuation N Y PA Document
00310461639 BREZTRI AEROSPHERE budesonide/glycopyr/formoterol HFA AER AD 160 mcg-9 mcg-4.8 mcg/actuation N Y PA Document
00173088710 TRELEGY ELLIPTA fluticasone/umeclidin/vilanter BLST W/DEV 100 mcg-62.5 mcg-25 mcg/actuation N Y PA Document
00173088714 TRELEGY ELLIPTA fluticasone/umeclidin/vilanter BLST W/DEV 100 mcg-62.5 mcg-25 mcg/actuation N Y PA Document
00173088761 TRELEGY ELLIPTA fluticasone/umeclidin/vilanter BLST W/DEV 100 mcg-62.5 mcg-25 mcg/actuation N Y PA Document
00173089310 TRELEGY ELLIPTA fluticasone/umeclidin/vilanter BLST W/DEV 200 mcg-62.5 mcg-25 mcg/actuation N Y PA Document
00173089314 TRELEGY ELLIPTA fluticasone/umeclidin/vilanter BLST W/DEV 200 mcg-62.5 mcg-25 mcg/actuation N Y PA Document
00173089361 TRELEGY ELLIPTA fluticasone/umeclidin/vilanter BLST W/DEV 200 mcg-62.5 mcg-25 mcg/actuation N Y PA Document
00310460012 BEVESPI AEROSPHERE glycopyrrolate/formoterol fum HFA AER AD 9 mcg-4.8 mcg N Y PA Document
00597015561 STIOLTO RESPIMAT tiotropium Br/olodaterol HCl MIST INHAL 2.5 mcg-2.5 mcg/actuation Y Y  
00597015570 STIOLTO RESPIMAT tiotropium Br/olodaterol HCl MIST INHAL 2.5 mcg-2.5 mcg/actuation Y Y  
00173086906 ANORO ELLIPTA umeclidinium brm/vilanterol tr BLST W/DEV 62.5 mcg-25 mcg/actuation Y Y  
00173086910 ANORO ELLIPTA umeclidinium brm/vilanterol tr BLST W/DEV 62.5 mcg-25 mcg/actuation Y Y  
66993013497 UMECLIDINIUM-VILANTEROL umeclidinium brm/vilanterol tr BLST W/DEV 62.5 mcg-25 mcg/actuation Y Y