Respiratory Agents
Antiasthmatics, Bronchodilators

Brand/Generic Name Dosage/Strength Status Restrictions Notes Relative Cost
AccuNeb generic.gif (400 bytes)
albuterol sulfate		 Solution for Nebulization   approved.gif (510 bytes)  

$$
Atrovent
Ipratropium Bromide		 Aerosol Soln   approved.gif (510 bytes)

ql.gif

$$$
Atrovent generic.gif (400 bytes)
Ipratropium Bromide		 Solution   approved.gif (510 bytes)

ql.gif

$$$
Atrovent HFA
ipratropium bromide		 17 mcg/actuation HFA Aerosol Inhaler   approved.gif (510 bytes)

ql.gif

$$$
Brethine generic.gif (400 bytes)
terbutaline		 tablet   approved.gif (510 bytes)  

$
Brovana
arformoterol		 15 mcg/2 mL Solution for Nebulization   nonform.gif (625 bytes)

priorauth.gif (377 bytes) ql.gif

Not Applicable
DuoNeb generic.gif (400 bytes)
ipratropium-albuterol		 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization   approved.gif (510 bytes)

ql.gif

Not Applicable
Foradil Aerolizer
formoterol fumarate		 12 mcg capsule, w/inhalation device   nonform.gif (625 bytes)

ql.gif

Not Applicable
ipratropium bromide generic.gif (400 bytes)
ipratropium bromide		 0.02 % Solution   approved.gif (510 bytes)  

$$$
Maxair Autohaler
pirbuterol		 200 mcg/Inhalation Aerosol Breath Activated   nonform.gif (625 bytes)

ql.gif

Not Applicable
Metaprel Inhaler
Metaproterenol Sulfate		   approved.gif (510 bytes)  

$$
Perforomist
formoterol fumarate		 20 mcg/2 mL Solution for Nebulization   nonform.gif (625 bytes)

priorauth.gif (377 bytes) ql.gif

Not Applicable
ProAir HFA
albuterol sulfate		 90 mcg/actuation HFA Aerosol Inhaler   approved.gif (510 bytes)

ql.gif

Not Applicable
Proventil generic.gif (400 bytes)
albuterol		 90 mcg/actuation Aerosol   approved.gif (510 bytes)

ql.gif

$
Proventil HFA
albuterol sulfate		 90 mcg/actuation HFA Aerosol Inhaler   nonform.gif (625 bytes)

priorauth.gif (377 bytes) ql.gif

Not Applicable
Quibron-T
theophylline		 tablet   nonform.gif (625 bytes)  

Not Applicable
Quibron-T/SR generic.gif (400 bytes)
theophylline		 tablet extended release 12 hr   approved.gif (510 bytes)  

$$
Serevent Diskus
salmeterol		 50 mcg/dose Disk with Device   approved.gif (510 bytes)

ql.gif

$$$$$
Spiriva with HandiHaler
tiotropium bromide		 18 mcg capsule, w/inhalation device   approved.gif (510 bytes)

ql.gif

$$$$$
Theochron generic.gif (400 bytes)
theophylline		 tablet extended release 12 hr   approved.gif (510 bytes)  

$
Tudorza Pressair
aclidinium bromide		 400 mcg/actuation Aerosol Powdr Breath Activated   approved.gif (510 bytes)  

$$$$$
Uniphyl generic.gif (400 bytes)
Theophylline		 Table SR 24 HR - 400mg   approved.gif (510 bytes)  

$$$
Uniphyl generic.gif (400 bytes)
Theophylline		 Table SR 24 HR - 600mg   approved.gif (510 bytes)  

$$$
Uniphyl generic.gif (400 bytes)
theophylline		 tablet extended release   approved.gif (510 bytes)  

$$$
Ventolin HFA
albuterol sulfate		 90 mcg/actuation HFA Aerosol Inhaler   approved.gif (510 bytes)

ql.gif

$
Vospire ER generic.gif (400 bytes)
albuterol sulfate		 tablet extended release 12 hr   approved.gif (510 bytes)  

$$$
Xopenex generic.gif (400 bytes)
levalbuterol HCl		 0.31 mg/3 mL Solution for Nebulization; 0.63 mg/3 mL Solution for Nebulization; 1.25 mg/3 mL Solution for Nebulization   nonform.gif (625 bytes)

ql.gif

Not Applicable
Xopenex Concentrate generic.gif (400 bytes)
levalbuterol HCl		 1.25 mg/0.5 mL Solution for Nebulization   nonform.gif (625 bytes)

ql.gif

Not Applicable
Xopenex HFA
levalbuterol tartrate		 45 mcg/actuation HFA Aerosol Inhaler   nonform.gif (625 bytes)

ql.gif

Not Applicable

Key for Product(s) Listed Above
Formulary Prior Authorization (PA may not be required for some benefit plans) Non-Formulary
(Third tier coverage applies for selected plans)		 Not Reimbursed
Quantity Limit Not available through mail order as 90-day supply* Step Therapy Generic Available. Brand name medication may be covered at a higher member cost or may not be covered for certain plans.
Notes $Relative cost compared to others in category Specialty distribution for selected plans (Fourth or fifth tier coverage applied for selected plans)

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