Antihistamines, Second Generation
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.
| Generic Name | Brand Name | Form | PDL Status |
Current Drug Use Criteria | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| cetirizine HCl | CETIRIZINE HCL | TABLET | Y | N | ||
| cetirizine HCl | ALLERGY RELIEF | TABLET | Y | N | ||
| cetirizine HCl | 24HOUR ALLERGY | TABLET | Y | N | ||
| cetirizine HCl | ALLERGY RELIEF | TABLET | Y | N | ||
| cetirizine HCl | WAL-ZYR | TABLET | Y | N | ||
| loratadine | LORATADINE | SOLUTION | Y | N | ||
| loratadine | ALLERGY RELIEF | SOLUTION | Y | N | ||
| loratadine | CHILDREN'S ALLERGY | SOLUTION | Y | N | ||
| loratadine | LORATADINE ALLERGY | SOLUTION | Y | N | ||
| loratadine | CHILDREN'S LORATADINE | SOLUTION | Y | N | ||
| loratadine | CHILDREN'S ALLERGY RELIEF | SOLUTION | Y | N | ||
| loratadine | ALLERGY RELIEF | TAB RAPDIS | Y | N | ||
| loratadine | LORATADINE | TAB RAPDIS | Y | N | ||
| loratadine | LORATADINE | TAB RAPDIS | Y | N | ||
| loratadine | CLARITIN | TAB RAPDIS | Y | N | ||
| loratadine | WAL-ITIN | TAB RAPDIS | Y | N | ||
| loratadine | ALLERGY RELIEF | TAB RAPDIS | Y | N | ||
| loratadine | ALLERCLEAR | TABLET | Y | N | ||
| loratadine | LORATADINE | TABLET | Y | N | ||
| loratadine | WAL-ITIN | TABLET | Y | N | ||
| loratadine | LORADAMED | TABLET | Y | N | ||
| loratadine | ALLERCLEAR | TABLET | Y | N | ||
| cetirizine HCl | CHILDREN'S ALL DAY ALLERGY | SOLUTION | N | Pharmacy PA | N | |
| cetirizine HCl | CHILDREN'S CETIRIZINE HCL | SOLUTION | N | Pharmacy PA | N | |
| cetirizine HCl | CETIRIZINE HCL | TAB CHEW | N | Pharmacy PA | N | |
| desloratadine | CLARINEX | TABLET | N | Pharmacy PA | N | |
| desloratadine | DESLORATADINE | TABLET | N | Pharmacy PA | N | |
| fexofenadine HCl | CHILDREN'S ALLERGY | ORAL SUSP | N | Pharmacy PA | N | |
| fexofenadine HCl | ALLERGY RELIEF | TABLET | N | Pharmacy PA | N | |
| levocetirizine dihydrochloride | 24HR ALLERGY RELIEF | TABLET | N | Pharmacy PA | N | |
| levocetirizine dihydrochloride | LEVOCETIRIZINE DIHYDROCHLORIDE | TABLET | N | Pharmacy PA | N | |
| loratadine | CHILDREN'S ALLERGY RELIEF | TAB CHEW | N | Pharmacy PA | N |