COPD AGENTS | Vendor Drug Program

Brand Name/Generic Name	NDC/Manufacturer	FFS Clinical Prior Auth Required	PDL Prior Auth Required	Programs
ANORO ELLIPTA 62.5-25 MCG INH umeclidinium brm/vilanterol tr	00173086910 GLAXOSMITHKLINE	Yes	No	Medicaid CHIP CSHCN
ATROVENT 17 MCG HFA INHALER ipratropium bromide	00597008717 BOEHRINGER ING.	No	No	Medicaid CHIP CSHCN
COMBIVENT RESPIMAT 20-100 MCG ipratropium/albuterol sulfate	00597002402 BOEHRINGER ING.	Yes	No	Medicaid CHIP CSHCN
IPRAT-ALBUT 0.5-3(2.5) MG/3 ML ipratropium/albuterol sulfate	76204060005 RITEDOSE PHARMA	Yes	No	Medicaid CHIP CSHCN
IPRAT-ALBUT 0.5-3(2.5) MG/3 ML ipratropium/albuterol sulfate	76204060012 RITEDOSE PHARMA	Yes	No	Medicaid CHIP CSHCN
IPRAT-ALBUT 0.5-3(2.5) MG/3 ML ipratropium/albuterol sulfate	76204060030 RITEDOSE PHARMA	Yes	No	Medicaid CHIP CSHCN HTWPlus
IPRAT-ALBUT 0.5-3(2.5) MG/3 ML ipratropium/albuterol sulfate	76204060060 RITEDOSE PHARMA	Yes	No	Medicaid CHIP CSHCN HTWPlus
IPRAT-ALBUT 0.5-3(2.5) MG/3 ML ipratropium/albuterol sulfate	00487020101 NEPHRON CORP	Yes	No	Medicaid CHIP CSHCN HTWPlus
IPRAT-ALBUT 0.5-3(2.5) MG/3 ML ipratropium/albuterol sulfate	00487020103 NEPHRON CORP	Yes	No	Medicaid CHIP CSHCN HTWPlus
IPRAT-ALBUT 0.5-3(2.5) MG/3 ML ipratropium/albuterol sulfate	00487020160 NEPHRON CORP	Yes	No	Medicaid CHIP CSHCN HTWPlus