Pharmacy Prior Authorization Criteria

Short-Acting Bronchodilators

For diagnosis of Bronchospasm
Indicated in adults and children 4 years of age and older for the treatment or prevention of bronchospasm with reversible obstructive airway disease and for the prevention of exercise-induced bronchospasm.

For diagnosis of Bronchospasm
Indicated for the treatment or prevention of bronchospasm in adults, adolescents, and children 4 years of age and older with reversible obstructive airway disease.

For diagnosis of Bronchospasm
Indicated for the treatment of or prevention of bronchospasm in patients 4 years of age and older with reversible obstructive airway disease.
For diagnosis of Exercise-Induced Bronchospasm
Indicated for the prevention of exercise-induced bronchospasm in patients 4 years of age and older.

Step Therapy

Length of Approval: 12 months

Requested drug is being used for a Food and Drug Administration (FDA)-approved indication

AND

2024-02-21, 2023-02-23, 2022-10-13, 2022-03-01, 2021-09-28, 2021-05-26, 2021-05-25, 2021-02-22, 2020-07-30, 2020-02-19, 2019-10-02

Proventil HFA [prescribing information]. Whitehouse Station, NJ: Merck & Co. Inc; October 2019.
Xopenex HFA [prescribing information]. Marlborough, MA: Sunovion Pharmaceuticals Inc; November 2023.
Ventolin HFA [prescribing information]. Research Triangle Park, NC: GlaxoSmithKline; August 2021.
Proair HFA [prescribing information]. Parsippany, NJ: Teva Respiratory, LLC; September 2022.
Proair Digihaler [prescribing information]. Parsippany, NJ: Teva Respiratory, LLC; February 2024.
Proair Respiclick [prescribing information]. Parsippany, NJ: Teva Respiratory, LLC; September 2022.

2024-02-21: 2024 UM Annual Review. Added in minimum 30 day trial duration to ST criteria. Background updates.
2023-02-23: 2023 UM Annual Review. No changes to clinical criteria. Updated background and references.
2022-10-13: GPI Reclassification
2022-03-01: 2022 Annual Review - added criterion "Requested drug is being used for FDA-approved indication", updated background information
2021-09-28: Addition of EHB formulary to guideline, no changes to criteria
2021-05-26: Addition of EHB formulary to guideline, no changes to criteria
2021-05-25: Addition of EHB formulary to guideline, no changes to criteria
2021-02-22: Annual review, no updates
2020-07-30: Formulary strategy update for all branded albuterol products to step through generic albuterol.
2020-02-19: annual review no changes to clinical criteria
2019-10-02: Changed second criteria from saying "One of the following: ProAir HFA or ProAir Respiclick" to One ProAir formulation (e.g. ProAir HFA, ProAir Respiclick, ProAir DigiHaler)