Antiasthmatics, Bronchodilators
 
Brand/Generic Name
(Generics in italics) |
Dosage/Strength |
Status |
Restrictions |
Notes |
Copayment
Tier |
| Key for Product(s) Listed Above |
 Formulary |
 | Non-Covered Medications that have Covered Alternatives |
|
 | Medicare Excluded |
|
 | Generic is Formulary, Brand is Non-Formulary |
|
 | Prior Authorization |
|
 Quantity Limit |
 Step Therapy |
 Determination of Part B or D |
 Notes |
|
| Tier 2 | Preferred Brand-Name Drugs |
|
|
| Tier 4 | Specialty medications with a cost of over $600 per month |
|
| Not Covered | This medication is not on the UPMC for Life formulary. Click “Show Alternative Medications” above |
|
|
|
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