Antihistamines, First Generation

← Back to Class List

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.

Alternate detailed view >

Generic Name Brand Name Form PDL
Status		 Current Drug Use Criteria Carveout
‐ Bill FFS		 New Drug Evaluation & Updates
triprolidine HCl HISTEX PDX DROPS N Pharmacy PA N  
carbinoxamine maleate CARBZAH LIQUID   N  
carbinoxamine maleate CARBINOXAMINE MALEATE LIQUID   N  
carbinoxamine maleate CARBINOXAMINE MALEATE ER SUS ER 12H   N  
carbinoxamine maleate RYVENT TABLET   N  
chlorpheniramine maleate CHLO-AMINE TAB CHEW   N  
chlorpheniramine maleate ALLERGY-TIME TABLET   N  
chlorpheniramine maleate ALLERGY RELIEF TABLET   N  
clemastine fumarate CLEMASTINE FUMARATE SYRUP   N  
clemastine fumarate CLEMSZA TABLET   N  
cyproheptadine HCl CYPROHEPTADINE HCL TABLET   N  
dexchlorpheniramine maleate DEXCHLORPHENIRAMINE MALEATE TABLET ER   N  
diphenhydramine HCl ALLERGY CAPSULE   N  
diphenhydramine HCl ALLERGY RELIEF CAPSULE   N  
diphenhydramine HCl DIPHENHYDRAMINE HCL CAPSULE   N  
diphenhydramine HCl BANOPHEN CAPSULE   N  
diphenhydramine HCl ALLERGY RELIEF LIQUID   N  
diphenhydramine HCl DIPHENHYDRAMINE HCL LIQUID   N  
diphenhydramine HCl CHILDREN'S ALLERGY LIQUID   N  
diphenhydramine HCl CHILDREN'S ALLERGY RELIEF TAB CHEW   N  
diphenhydramine HCl ALLERGY TABLET   N  
diphenhydramine HCl ALLERGY RELIEF TABLET   N  
hydroxyzine HCl HYDROXYZINE HCL TABLET   N  
hydroxyzine pamoate VISTARIL CAPSULE   N  
triprolidine HCl TRIPROLIDINE HCL DROPS   N  
triprolidine HCl HISTEX PD DROPS   N  
triprolidine HCl HISTEX LIQUID   N  
Back to Top ↑