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Commercial Name:<br/> Proventil <br/>Active Ingredient:<br/> Albuterol<br/>Medical form: Inhaler<br/>Utilization:<br/> Used to relieve symptoms of asthma, to treat patients with chronic obstructive bronchitis. It works relaxing muscles of bronchi and widening the airways<br/>Available Dosages: 100 mg<br/>Commercial Name: Ventolin <br/>Active Ingredient: Albuterol<br/>Utilization: Used to relieve symptoms of asthma, to treat patients with chronic obstructive bronchitis. It works relaxing muscles of bronchi and widening the airways<br/>Available Dosages: 100mcg<br/> Ventolin <br/>Medical form: Pills<br/>Available Dosages: 2 mg, 4 mg
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Otherwise please return completed form to: UPMC HEALTH PLAN PHARMACY SERVICES PHONE 800-396-4139 FAX 412-454-7722 PLEASE TYPE ventolin OR PRINT NEATLY Please complete all sections of this form AND include details of past relevant medical treatment, which substantiates the need for an exception to using formulary alternatives, i .
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