Antihistamines, Second Generation

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PDL Reference Documents

PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

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Generic Name Brand Name Form PDL
Status		 Current Drug Use Criteria Carveout
‐ Bill FFS		 New Drug Evaluation & Updates
cetirizine HCl CETIRIZINE HCL SOLUTION Y    
cetirizine HCl CHILDREN'S ALL DAY ALLERGY SOLUTION Y    
cetirizine HCl CHILDREN'S ALLERGY RELIEF SOLUTION Y    
cetirizine HCl CHILDREN'S CETIRIZINE HCL SOLUTION Y    
cetirizine HCl ALL DAY ALLERGY SOLUTION Y    
cetirizine HCl ALLERGY RELIEF SOLUTION Y    
cetirizine HCl CETIRIZINE HCL SOLUTION Y    
cetirizine HCl CHILDREN'S ALL DAY ALLERGY SOLUTION Y    
cetirizine HCl CHILDREN'S ALLERGY SOLUTION Y    
cetirizine HCl CHILDREN'S ALLERGY RELIEF SOLUTION Y    
cetirizine HCl WAL-ZYR SOLUTION Y    
cetirizine HCl CHILDREN'S ZYRTEC SOLUTION Y    
cetirizine HCl CHILDREN'S WAL-ZYR SOLUTION Y    
cetirizine HCl CHILDREN'S CETIRIZINE HCL SOLUTION Y    
cetirizine HCl CHILDREN'S ALLER-TEC SOLUTION Y    
cetirizine HCl ALL DAY ALLERGY TABLET Y    
cetirizine HCl ALLERGY RELIEF TABLET Y    
cetirizine HCl CETIRIZINE HCL TABLET Y    
cetirizine HCl 24HOUR ALLERGY TABLET Y    
cetirizine HCl ALL DAY ALLERGY TABLET Y    
cetirizine HCl ALLERGY TABLET Y    
cetirizine HCl ALLERGY RELIEF TABLET Y    
cetirizine HCl ALLER-TEC TABLET Y    
cetirizine HCl CETIRIZINE HCL TABLET Y    
cetirizine HCl ZYRTEC TABLET Y    
cetirizine HCl WAL-ZYR TABLET Y    
desloratadine DESLORATADINE TABLET Y    
desloratadine CLARINEX TABLET Y    
fexofenadine HCl ALLER-EASE TABLET Y    
fexofenadine HCl ALLERGY RELIEF TABLET Y    
fexofenadine HCl FEXOFENADINE HCL TABLET Y    
fexofenadine HCl WAL-FEX ALLERGY TABLET Y    
fexofenadine HCl ALLER-EASE TABLET Y    
fexofenadine HCl ALLERGY RELIEF TABLET Y    
fexofenadine HCl FEXOFENADINE HCL TABLET Y    
fexofenadine HCl ALLERGY-HIVES RELIEF TABLET Y    
fexofenadine HCl ALLEGRA ALLERGY TABLET Y    
fexofenadine HCl ALLER-FEX TABLET Y    
fexofenadine HCl ALLEGRA HIVES TABLET Y    
levocetirizine dihydrochloride ALLERGY RELIEF TABLET Y    
levocetirizine dihydrochloride LEVOCETIRIZINE DIHYDROCHLORIDE TABLET Y    
levocetirizine dihydrochloride 24HR ALLERGY RELIEF TABLET Y    
levocetirizine dihydrochloride XYZAL TABLET Y    
levocetirizine dihydrochloride LEVOCETIRIZINE DIHYDROCHLORIDE TABLET Y    
levocetirizine dihydrochloride ALLERGY RELIEF TABLET Y    
levocetirizine dihydrochloride 24HR ALLERGY RELIEF TABLET Y    
loratadine ALLERGY RELIEF SOLUTION Y    
loratadine CHILDREN'S ALLERGY SOLUTION Y    
loratadine LORATADINE SOLUTION Y    
loratadine CHILDREN'S ALLERGY RELIEF SOLUTION Y    
loratadine LORATADINE ALLERGY SOLUTION Y    
loratadine CHILDREN'S LORATADINE SOLUTION Y    
loratadine ALLERGY RELIEF SOLUTION Y    
loratadine CHILDREN'S ALLERGY SOLUTION Y    
loratadine CHILDREN'S ALLERGY RELIEF SOLUTION Y    
loratadine CHILDREN'S CLARITIN SOLUTION Y    
loratadine CHILDREN'S LORATADINE SOLUTION Y    
loratadine CLARITIN SOLUTION Y    
loratadine LORATADINE SOLUTION Y    
loratadine WAL-ITIN SOLUTION Y    
loratadine ALLERGY RELIEF TAB RAPDIS Y    
loratadine LORATADINE TAB RAPDIS Y    
loratadine ALLERGY RELIEF TAB RAPDIS Y    
loratadine ALAVERT TAB RAPDIS Y    
loratadine LORATADINE TAB RAPDIS Y    
loratadine CLARITIN TAB RAPDIS Y    
loratadine WAL-ITIN TAB RAPDIS Y    
loratadine ALLERGY RELIEF TABLET Y    
loratadine ALL DAY ALLERGY RELIEF TABLET Y    
loratadine ALLERCLEAR TABLET Y    
loratadine LORATADINE TABLET Y    
loratadine ALLERCLEAR TABLET Y    
loratadine ALLERGY RELIEF TABLET Y    
loratadine CLARITIN TABLET Y    
loratadine LORATADINE TABLET Y    
loratadine WAL-ITIN TABLET Y    
loratadine LORADAMED TABLET Y    
cetirizine HCl ALL DAY ALLERGY RELIEF CAPSULE N Pharmacy PA  
cetirizine HCl CETIRIZINE HCL TAB CHEW N Pharmacy PA  
desloratadine DESLORATADINE SOLUTION N Pharmacy PA  
desloratadine DESLORATADINE TAB RAPDIS N Pharmacy PA  
fexofenadine HCl CHILDREN'S ALLERGY ORAL SUSP N Pharmacy PA  
levocetirizine dihydrochloride LEVOCETIRIZINE DIHYDROCHLORIDE SOLUTION N Pharmacy PA  
loratadine ALLERGY RELIEF CAPSULE N Pharmacy PA  
loratadine CHILDREN'S ALLERGY RELIEF TAB CHEW N Pharmacy PA  
loratadine CHILDREN'S LORATADINE TAB CHEW N Pharmacy PA  
loratadine LORATADINE TAB CHEW N Pharmacy PA  
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