2021 Essential Asthma Drug List Label Drug Name Generic Drug Name Formulary Status ACCOLATE TAB 10MG ZAFIRLUKAST Formulary ACCOLATE TAB 20MG ZAFIRLUKAST Formulary ADVAIR DISKU AER 100/50 FLUTICASONE PROPION/SALMETEROL Formulary ADVAIR DISKU AER 250/50 FLUTICASONE PROPION/SALMETEROL Formulary ADVAIR DISKU AER 500/50 FLUTICASONE PROPION/SALMETEROL Formulary ADVAIR HFA AER 45/21 FLUTICASONE PROPION/SALMETEROL Formulary ADVAIR HFA AER 115/21 FLUTICASONE PROPION/SALMETEROL Formulary ADVAIR HFA AER 230/21 FLUTICASONE PROPION/SALMETEROL Formulary AIRDUO DGHLR INH 113-14 FLUTICASONE PROPION/SALMETEROL Formulary AIRDUO DGHLR INH 232-14 FLUTICASONE PROPION/SALMETEROL Formulary AIRDUO DGHLR INH 55-14 FLUTICASONE PROPION/SALMETEROL Formulary AIRDUO RESPI INH 113-14 FLUTICASONE PROPION/SALMETEROL Formulary AIRDUO RESPI INH 232-14 FLUTICASONE PROPION/SALMETEROL Formulary AIRDUO RESPI INH 55-14 FLUTICASONE PROPION/SALMETEROL Formulary ALBUTEROL TAB 2MG ALBUTEROL SULFATE Formulary ALBUTEROL TAB 4MG ALBUTEROL SULFATE Formulary ALBUTEROL SYP 2MG/5ML ALBUTEROL SULFATE Formulary ALBUTEROL NEB 0.083% ALBUTEROL SULFATE Formulary ALBUTEROL NEB 0.5% ALBUTEROL SULFATE Formulary ALBUTEROL NEB 0.63MG/3 ALBUTEROL SULFATE Formulary ALBUTEROL NEB 1.25MG/3 ALBUTEROL SULFATE Formulary ALBUTEROL TAB 4MG ER ALBUTEROL SULFATE Formulary ALBUTEROL TAB 8MG ER ALBUTEROL SULFATE Formulary ALBUTEROL AER HFA ALBUTEROL SULFATE Formulary ALBUTEROL AER HFA ALBUTEROL SULFATE Non-Formulary ALVESCO AER 80MCG CICLESONIDE Formulary ALVESCO AER 160MCG CICLESONIDE Formulary AMINOPHYLLIN INJ 25MG/ML AMINOPHYLLINE Non-Formulary ARMONAIR AER 113/ACT FLUTICASONE PROPIONATE Formulary ARMONAIR AER 232/ACT FLUTICASONE PROPIONATE Formulary ARMONAIR AER 55/ACT FLUTICASONE PROPIONATE Formulary ARNUITY ELPT INH 100MCG FLUTICASONE FUROATE Formulary ARNUITY ELPT INH 200MCG FLUTICASONE FUROATE Formulary ARNUITY ELPT INH 50MCG FLUTICASONE FUROATE Formulary ASMANEX 120 AER 220MCG MOMETASONE FUROATE Formulary ASMANEX 60 AER 220MCG MOMETASONE FUROATE Formulary ASMANEX 14 AER 220MCG MOMETASONE FUROATE Formulary ASMANEX 30 AER 220MCG MOMETASONE FUROATE Formulary ASMANEX 30 AER 110MCG MOMETASONE FUROATE Formulary ASMANEX 7 AER 110MCG MOMETASONE FUROATE Formulary ASMANEX HFA AER 100 MCG MOMETASONE FUROATE Formulary ASMANEX HFA AER 200 MCG MOMETASONE FUROATE Formulary ASMANEX HFA AER 50MCG MOMETASONE FUROATE Formulary ASTHMANEFRIN NEB 2.25% RACEPINEPHRINE HCL Non-Formulary Page 1 of 4 ATROVENT HFA AER 17MCG IPRATROPIUM BROMIDE Formulary BREO ELLIPTA INH 200-25 FLUTICASONE/VILANTEROL Formulary BREO ELLIPTA INH 100-25 FLUTICASONE/VILANTEROL Formulary BRONKAID TAB 25-400MG EPHEDRINE SULFATE/GUAIFENESIN Non-Formulary BUDESONIDE SUS 0.25MG/2 BUDESONIDE Formulary BUDESONIDE SUS 0.5MG/2 BUDESONIDE Formulary BUDESONIDE SUS 1MG/2ML BUDESONIDE Formulary BUDES/FORMOT AER 160-4.5 BUDESONIDE/FORMOTEROL FUMARATE Non-Formulary BUDES/FORMOT AER 80-4.5 BUDESONIDE/FORMOTEROL FUMARATE Non-Formulary CINQAIR INJ RESLIZUMAB Non-Formulary COMBIVENT AER 20-100 IPRATROPIUM/ALBUTEROL SULFATE Formulary CROMOLYN SOD NEB 20MG/2ML CROMOLYN SODIUM Formulary CROMOLYN SOD SPR 5.2/ACT CROMOLYN SODIUM Non-Formulary DUAKLIR AER 400/12 ACLIDINIUM BROM/FORMOTEROL FUM Formulary DULERA AER 200-5MCG MOMETASONE/FORMOTEROL Formulary DULERA AER 100-5MCG MOMETASONE/FORMOTEROL Formulary DULERA AER 50-5MCG MOMETASONE/FORMOTEROL Formulary ELIXOPHYLLIN ELX 80/15ML THEOPHYLLINE ANHYDROUS Formulary FASENRA INJ 30MG/ML BENRALIZUMAB Non-Formulary FASENRA PEN INJ 30MG/ML BENRALIZUMAB Formulary FLOVENT DISK AER 50MCG FLUTICASONE PROPIONATE Formulary FLOVENT DISK AER 250MCG FLUTICASONE PROPIONATE Formulary FLOVENT DISK AER 100MCG FLUTICASONE PROPIONATE Formulary FLOVENT HFA AER 44MCG FLUTICASONE PROPIONATE Formulary FLOVENT HFA AER 110MCG FLUTICASONE PROPIONATE Formulary FLOVENT HFA AER 220MCG FLUTICASONE PROPIONATE Formulary FLUTIC/SALME INH 55/14 FLUTICASONE PROPION/SALMETEROL Formulary FLUTIC/SALME INH 113/14 FLUTICASONE PROPION/SALMETEROL Formulary FLUTIC/SALME INH 232/14 FLUTICASONE PROPION/SALMETEROL Formulary FLUTIC/SALME AER 100/50 FLUTICASONE PROPION/SALMETEROL Formulary FLUTIC/SALME AER 250/50 FLUTICASONE PROPION/SALMETEROL Formulary FLUTIC/SALME AER 500/50 FLUTICASONE PROPION/SALMETEROL Formulary IPRATROPIUM SOL 0.02%INH IPRATROPIUM BROMIDE Formulary IPRATROPIUM/ SOL ALBUTER IPRATROPIUM/ALBUTEROL SULFATE Formulary LEVALBUTEROL NEB 1.25/0.5 LEVALBUTEROL HCL Formulary LEVALBUTEROL NEB 0.31MG LEVALBUTEROL HCL Formulary LEVALBUTEROL NEB 0.63MG LEVALBUTEROL HCL Formulary LEVALBUTEROL NEB 1.25MG LEVALBUTEROL HCL Formulary LEVALBUTEROL AER 45/ACT LEVALBUTEROL TARTRATE Non-Formulary METAPROTEREN SYP 10MG/5ML METAPROTERENOL SULFATE Formulary METAPROTEREN TAB 10MG METAPROTERENOL SULFATE Formulary METAPROTEREN TAB 20MG METAPROTERENOL SULFATE Formulary MONTELUKAST CHW 4MG MONTELUKAST SODIUM Formulary MONTELUKAST CHW 5MG MONTELUKAST SODIUM Formulary MONTELUKAST TAB 10MG MONTELUKAST SODIUM Formulary MONTELUKAST GRA 4MG MONTELUKAST SODIUM Formulary NASALCROM SPR 5.2/ACT CROMOLYN SODIUM Non-Formulary Page 2 of 4 NUCALA INJ 100MG MEPOLIZUMAB Medical Benefit NUCALA INJ 100MG/ML MEPOLIZUMAB Formulary PRIMATENE AER 0.125MG EPINEPHRINE Non-Formulary PROAIR DIGIH AER 108MCG ALBUTEROL SULFATE Formulary PROAIR HFA AER ALBUTEROL SULFATE Formulary PROAIR RESPI AER ALBUTEROL SULFATE Formulary PROVENTIL AER HFA ALBUTEROL SULFATE Non-Formulary PULMICORT SUS 0.25MG/2 BUDESONIDE Non-Formulary PULMICORT SUS 0.5MG/2 BUDESONIDE Non-Formulary PULMICORT SUS 1MG/2ML BUDESONIDE Non-Formulary PULMICORT INH 180MCG BUDESONIDE Formulary PULMICORT INH 90MCG BUDESONIDE Formulary QVAR REDIHAL AER 40MCG BECLOMETHASONE DIPROPIONATE Formulary QVAR REDIHA AER 80MCG BECLOMETHASONE DIPROPIONATE Formulary S2 NEB 2.25% RACEPINEPHRINE HCL Non-Formulary SEEBRI NEOHA CAP 15.6MCG GLYCOPYRROLATE Formulary SEREVENT DIS AER 50MCG SALMETEROL XINAFOATE Formulary SINGULAIR GRA 4MG MONTELUKAST SODIUM Non-Formulary SINGULAIR CHW 4MG MONTELUKAST SODIUM Non-Formulary SINGULAIR TAB 10MG MONTELUKAST SODIUM Non-Formulary SINGULAIR CHW 5MG MONTELUKAST SODIUM Non-Formulary SPIRIVA CAP HANDIHLR TIOTROPIUM BROMIDE Formulary SPIRIVA AER 1.25MCG TIOTROPIUM BROMIDE Formulary SYMBICORT AER 160-4.5 BUDESONIDE/FORMOTEROL FUMARATE Formulary SYMBICORT AER 80-4.5 BUDESONIDE/FORMOTEROL FUMARATE Formulary TERBUTALINE TAB 2.5MG TERBUTALINE SULFATE Formulary TERBUTALINE TAB 5MG TERBUTALINE SULFATE Formulary TERBUTALINE INJ 1MG/ML TERBUTALINE SULFATE Formulary THEO-24 CAP 100MG CR THEOPHYLLINE ANHYDROUS Formulary THEO-24 CAP 200MG CR THEOPHYLLINE ANHYDROUS Formulary THEO-24 CAP 300MG CR THEOPHYLLINE ANHYDROUS Formulary THEO-24 CAP 400MG ER THEOPHYLLINE ANHYDROUS Formulary THEOCHRON TAB 100MG CR THEOPHYLLINE ANHYDROUS Formulary THEOCHRON TAB 200MG CR THEOPHYLLINE ANHYDROUS Formulary THEOPHYLLINE SOL 80/15ML THEOPHYLLINE ANHYDROUS Formulary THEOPHYLLINE TAB 200MG CR THEOPHYLLINE ANHYDROUS Formulary THEOPHYLLINE TAB 100MG CR THEOPHYLLINE ANHYDROUS Formulary THEOPHYLLINE TAB 450MG ER THEOPHYLLINE ANHYDROUS Formulary THEOPHYLLINE TAB 300MG ER THEOPHYLLINE ANHYDROUS Formulary THEOPHYLLINE TAB 400MG ER THEOPHYLLINE ANHYDROUS Formulary THEOPHYLLINE TAB 600MG ER THEOPHYLLINE ANHYDROUS Formulary UTIBRON CAP NEOHALER INDACATEROL/GLYCOPYRROLATE Formulary VENTOLIN HFA AER ALBUTEROL SULFATE Formulary WIXELA INHUB AER 100/50 FLUTICASONE PROPION/SALMETEROL Formulary WIXELA INHUB AER 250/50 FLUTICASONE PROPION/SALMETEROL Formulary WIXELA INHUB AER 500/50 FLUTICASONE PROPION/SALMETEROL Formulary XOLAIR INJ 75/0.5 OMALIZUMAB Medical Benefit Page 3 of 4 XOLAIR INJ 150MG/ML OMALIZUMAB Medical Benefit XOLAIR SOL 150MG OMALIZUMAB Medical Benefit XOPENEX NEB 0.31MG LEVALBUTEROL HCL Formulary XOPENEX NEB 0.63MG LEVALBUTEROL HCL Formulary XOPENEX NEB 1.25/3ML LEVALBUTEROL HCL Formulary XOPENEX CONC NEB 1.25/0.5 LEVALBUTEROL HCL Formulary XOPENEX HFA AER LEVALBUTEROL TARTRATE Non-Formulary YUPELRI SOL REVEFENACIN Formulary ZAFIRLUKAST TAB 20MG ZAFIRLUKAST Formulary ZAFIRLUKAST TAB 10MG ZAFIRLUKAST Formulary ZILEUTON ER TAB 600MG ZILEUTON Formulary ZYFLO TAB 600MG ZILEUTON Formulary ZYFLO CR TAB 600MG ZILEUTON Formulary Page 4 of 4.