CurrentAnthemPolicy N/A

Asthma medication formulary and prior authorization guidance

Guidance on preferred and nonpreferred asthma controller and rescue products and prior authorization notes for New York Medicaid providers and patients; affects prescribing and pharmacy claims.

Policy Summary

PayerAnthem

PolicyAsthma medication formulary and prior authorization guidance

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPrior authorization is required for children younger than 6 for certain products; verify coverage and prescribe preferred products when possible.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multiplelisted controller products (preferred and nonpreferred)

multiplelisted rescue products (preferred and nonpreferred)

children <6prior authorization exception noted

90-dayretail pharmacy supply allowed for controller medications

Formulary and Coverage Summary

Formulary listings

Formulary status for asthma medications is presented by category and preferred status.

Controller - Nonpreferred: Alvesco (ciclesonide); ArmonAir Digihaler (fluticasone propionate); Asmanex HFA (mometasone furoate); Asmanex Twisthaler (mometasone furoate); Pulmicort Flexhaler (budesonide); Qvar Redihaler (beclomethasone).

Controller - Preferred: Arnuity Ellipta (fluticasone furoate); Budesonide suspension nebules (generic Pulmicort Respules suspension); fluticasone propionate Diskus & HFA.

Controller - Additional Nonpreferred: Advair HFA & Diskus (fluticasone/salmeterol); AirDuo Respiclick & Digihaler (fluticasone/salmeterol); Breo Ellipta (fluticasone/vilanterol); Dulera (mometasone/formoterol); Symbicort (budesonide/formoterol).

Policy Summary

PayerAnthem

PolicyAsthma medication formulary and prior authorization guidance

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPrior authorization is required for children younger than 6 for certain products; verify coverage and prescribe preferred products when possible.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Formulary status for inhaled asthma medications under New York Medicaid is presented by therapeutic category and preferred status. Controller products are listed as either Preferred (for example, Arnuity Ellipta, Budesonide suspension nebules, and fluticasone propionate Diskus & HFA) or Nonpreferred (for example, Alvesco, ArmonAir Digihaler, Asmanex HFA, Asmanex Twisthaler, Pulmicort Flexhaler, and Qvar Redihaler). Combination ICS/LABA controller products are similarly categorized with examples of both preferred and nonpreferred brands. Rescue products (short-acting bronchodilators) are also split by status: Preferred includes generic albuterol HFA and albuterol nebules, while Nonpreferred includes branded and some device-specific albuterol formulations (for example, ProAir Digihaler, Ventolin HFA, and Levalbuterol products).

Provider Requirements and Pharmacy Impact

Prior Authorization

Prior Authorization Required for Young Children

Prior authorization is required for children younger than 6 for certain asthma controller medications. Verify PA requirements before prescribing to avoid pharmacy delays or claim denials.

Applies to select controller medications for children <6
Members can fill a 90-day supply at retail pharmacies for controller medications

Step Therapy

Step Therapy Possible

Step therapy may apply — some members must try a preferred agent before coverage will be provided for non-preferred products. Prescribing a preferred product when appropriate can reduce the chance of step edits and PA requests.

Non-preferred products are subject to step therapy and may require PA
Preferred products can still require PA or other utilization management

Note

Verify Coverage and Formulary Status

Coverage and formulary status change periodically. Always verify member coverage, product preference (preferred vs non-preferred), and PA/step therapy rules on the payer provider website prior to prescribing or dispensing.

Confirm product is preferred to reduce claim rejection risk
Check PA and step therapy requirements online before prescribing

Denial Risk

Claims and Formulary Risk

Non-preferred products may lead to claim rejections at the point of sale. Even preferred products can incur PA or step therapy edits; submitting the correct PA or following step therapy requirements reduces denial risk.

Prescribe preferred products when possible to minimize rejections
If a claim is rejected, confirm PA/step therapy status and submit required documentation or appeal as appropriate

Product Definitions

Controller products — inhaled corticosteroids and combination controller definitions

DefinitionInhaled corticosteroids (ICS) and combination ICS/long-acting beta-agonist (LABA) products used for long-term control of asthma; listed in the document as controller products (preferred and nonpreferred).

Examples - NonpreferredAlvesco (ciclesonide); ArmonAir Digihaler (fluticasone propionate); Asmanex HFA (mometasone furoate); Asmanex Twisthaler (mometasone furoate); Pulmicort Flexhaler (budesonide); Qvar Redihaler (beclomethasone).

Examples - PreferredArnuity Ellipta (fluticasone furoate); Budesonide suspension nebules (generic Pulmicort Respules suspension); Fluticasone propionate (Diskus & HFA).

Combination controller examplesNonpreferred: Advair HFA & Diskus (fluticasone/salmeterol); AirDuo Respiclick & Digihaler (fluticasone/salmeterol); Breo Ellipta (fluticasone/vilanterol); Dulera (mometasone/formoterol); Symbicort (budesonide/formoterol). Preferred: Budesonide/formoterol (generic Symbicort); Breyna (budesonide/formoterol); Fluticasone/salmeterol (generic AirDuo Respiclick and authorized generic Advair Diskus); Wixela Inhub (fluticasone/salmeterol).

Rescue products — short-acting bronchodilators and combination rescue inhaler definitions

DefinitionShort-acting bronchodilators and combination rescue inhalers used for acute symptom relief; listed in the document as rescue products (preferred and nonpreferred).

Examples - NonpreferredLevalbuterol HFA & nebules (generic and brand Xopenex); Proair Digihaler, HFA, & Respiclick (albuterol); Proventil HFA (albuterol); Ventolin HFA (albuterol).

Examples - PreferredAlbuterol nebules; Albuterol HFA (generic Proair, Proventil, and Ventolin); Combivent Respimat (ipratropium/albuterol); Ipratropium/albuterol nebules.

Clinical roleUsed for rapid relief of acute bronchospasm and exacerbation symptoms; formulary status may be preferred or nonpreferred as listed.

OpenPayer

Asthma medication formulary and prior authorization guidance

Formulary and Coverage Summary

Billing and Codes

Provider Requirements and Pharmacy Impact

Background and Scope

Product Definitions