Antihistamines, First 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
chlorpheniramine maleate ALLERGY RELIEF TABLET Y   N  
chlorpheniramine maleate ALLERGY TABLET Y   N  
chlorpheniramine maleate ALLER-CHLOR TABLET Y   N  
chlorpheniramine maleate ALLERGY-TIME TABLET Y   N  
chlorpheniramine maleate WAL-FINATE TABLET Y   N  
chlorpheniramine maleate CHLORTABS TABLET Y   N  
chlorpheniramine maleate CHLORPHENIRAMINE MALEATE TABLET Y   N  
chlorpheniramine maleate CHLORHIST TABLET Y   N  
chlorpheniramine maleate ALLERGY RELIEF TABLET Y   N  
chlorpheniramine maleate ALLERGY 4-HOUR TABLET Y   N  
chlorpheniramine maleate ALLERGY TABLET Y   N  
chlorpheniramine maleate PHARBECHLOR TABLET Y   N  
cyproheptadine HCl CYPROHEPTADINE HCL SYRUP Y   N  
cyproheptadine HCl CYPROHEPTADINE HCL TABLET Y   N  
diphenhydramine HCl SLEEP AID CAPSULE Y   N  
diphenhydramine HCl SLEEP-AID CAPSULE Y   N  
diphenhydramine HCl NIGHTTIME SLEEP AID CAPSULE Y   N  
diphenhydramine HCl DIPHENHYDRAMINE HCL CAPSULE Y   N  
diphenhydramine HCl DIMETANE CAPSULE Y   N  
diphenhydramine HCl BANOPHEN CAPSULE Y   N  
diphenhydramine HCl ALLERGY CAPSULE Y   N  
diphenhydramine HCl ALLERGY RELIEF CAPSULE Y   N  
diphenhydramine HCl NIGHTTIME SLEEP AID CAPSULE Y   N  
diphenhydramine HCl DORMIN CAPSULE Y   N  
diphenhydramine HCl PHARBEDRYL CAPSULE Y   N  
diphenhydramine HCl NIGHTTIME SLEEP GEL CAPSULE Y   N  
diphenhydramine HCl SLEEP AID CAPSULE Y   N  
diphenhydramine HCl MEDI-SLEEP CAPSULE Y   N  
diphenhydramine HCl EZ NITE SLEEP CAPSULE Y   N  
diphenhydramine HCl ZZZQUIL CAPSULE Y   N  
diphenhydramine HCl WAL-SOM CAPSULE Y   N  
diphenhydramine HCl WAL-SLEEP Z CAPSULE Y   N  
diphenhydramine HCl WAL-DRYL CAPSULE Y   N  
diphenhydramine HCl UNISOM SLEEPMINIS CAPSULE Y   N  
diphenhydramine HCl SLEEPING CAPSULE Y   N  
diphenhydramine HCl SLEEP-AID CAPSULE Y   N  
diphenhydramine HCl UNISOM CAPSULE Y   N  
diphenhydramine HCl BENADRYL CAPSULE Y   N  
diphenhydramine HCl BANOPHEN CAPSULE Y   N  
diphenhydramine HCl ALLERGY RELIEF CAPSULE Y   N  
diphenhydramine HCl ALLERGY MEDICATION CAPSULE Y   N  
diphenhydramine HCl ALLERGY CAPSULE Y   N  
diphenhydramine HCl ALER-CAPS CAPSULE Y   N  
diphenhydramine HCl ALLER MED CAPSULE Y   N  
diphenhydramine HCl DIPHEDRYL ALLERGY CAPSULE Y   N  
diphenhydramine HCl COMPLETE ALLERGY CAPSULE Y   N  
diphenhydramine HCl COMPLETE ALLERGY MEDICINE CAPSULE Y   N  
diphenhydramine HCl DIPHEDRYL CAPSULE Y   N  
diphenhydramine HCl DIPHENHYDRAMINE HCL CAPSULE Y   N  
diphenhydramine HCl ALLERGY RELIEF LIQUID Y   N  
diphenhydramine HCl SLEEP AID LIQUID Y   N  
diphenhydramine HCl SLEEP TIME LIQUID Y   N  
diphenhydramine HCl M-DRYL LIQUID Y   N  
diphenhydramine HCl EZZ NITE SLEEP AID LIQUID Y   N  
diphenhydramine HCl DIPHENHYDRAMINE HCL LIQUID Y   N  
diphenhydramine HCl DIPHEDRYL LIQUID Y   N  
diphenhydramine HCl CHILDREN'S ALLERGY RELIEF LIQUID Y   N  
diphenhydramine HCl CHILDREN'S ALLERGY LIQUID Y   N  
diphenhydramine HCl SILADRYL DAS LIQUID Y   N  
diphenhydramine HCl NIGHTTIME SLEEP AID LIQUID Y   N  
diphenhydramine HCl M-DRYL LIQUID Y   N  
diphenhydramine HCl MAXALLERGY KIDS LIQUID Y   N  
diphenhydramine HCl KOSHER CARE ALLERGY RELIEF LIQUID Y   N  
diphenhydramine HCl GERI-DRYL LIQUID Y   N  
diphenhydramine HCl ZZZQUIL LIQUID Y   N  
diphenhydramine HCl SILADRYL LIQUID Y   N  
diphenhydramine HCl WAL-DRYL ALLERGY LIQUID Y   N  
diphenhydramine HCl SLEEP AID LIQUID Y   N  
diphenhydramine HCl ALLERGY RELIEF LIQUID Y   N  
diphenhydramine HCl ALLERGY MEDICATION LIQUID Y   N  
diphenhydramine HCl ALLERGY LIQUID Y   N  
diphenhydramine HCl WAL-SLEEP Z LIQUID Y   N  
diphenhydramine HCl CHILDREN'S ALLERGY RELIEF LIQUID Y   N  
diphenhydramine HCl CHILDREN'S BENADRYL ALLERGY LIQUID Y   N  
diphenhydramine HCl CHILDREN'S WAL-DRYL ALLERGY LIQUID Y   N  
diphenhydramine HCl DIPHENHYDRAMINE HCL LIQUID Y   N  
diphenhydramine HCl CHILDREN'S ALLERGY LIQUID Y   N  
diphenhydramine HCl DIPHEDRYL LIQUID Y   N  
diphenhydramine HCl DIPHEDRYL ALLERGY LIQUID Y   N  
diphenhydramine HCl REST SIMPLY TABLET Y   N  
diphenhydramine HCl SLEEP AID TABLET Y   N  
diphenhydramine HCl SLEEP TABS TABLET Y   N  
diphenhydramine HCl NIGHTTIME SLEEP AID TABLET Y   N  
diphenhydramine HCl REST SIMPLY TABLET Y   N  
diphenhydramine HCl NYTOL QUICKCAPS TABLET Y   N  
diphenhydramine HCl SIMPLY SLEEP TABLET Y   N  
diphenhydramine HCl MILES NERVINE TABLET Y   N  
diphenhydramine HCl NIGHTTIME SLEEP AID TABLET Y   N  
diphenhydramine HCl SOMINEX MAX STRENGTH TABLET Y   N  
diphenhydramine HCl TWILITE TABLET Y   N  
diphenhydramine HCl SOMINEX TABLET Y   N  
diphenhydramine HCl SLEEP TABLET TABLET Y   N  
diphenhydramine HCl SLEEP II TABLET Y   N  
diphenhydramine HCl SLEEP AID TABLET Y   N  
diphenhydramine HCl BENADRYL ALLERGY TABLET Y   N  
diphenhydramine HCl ALKA-SELTZER PLUS ALLERGY TABLET Y   N  
diphenhydramine HCl DIPHENHYDRAMINE HCL TABLET Y   N  
diphenhydramine HCl COMPOZ TABLET Y   N  
hydroxyzine HCl HYDROXYZINE HCL TABLET Y   N  
hydroxyzine pamoate HYDROXYZINE PAMOATE CAPSULE Y   N  
carbinoxamine maleate CARBZAH LIQUID N Pharmacy PA N  
carbinoxamine maleate CARBINOXAMINE PD LIQUID N Pharmacy PA N  
carbinoxamine maleate CARBINOXAMINE MALEATE LIQUID N Pharmacy PA N  
carbinoxamine maleate CARBINOXAMINE LIQUID N Pharmacy PA N  
carbinoxamine maleate KARBINAL ER SUS ER 12H N Pharmacy PA N  
carbinoxamine maleate CARBINOXAMINE MALEATE ER SUS ER 12H N Pharmacy PA N  
carbinoxamine maleate RYVENT TABLET N Pharmacy PA N  
carbinoxamine maleate CARBINOXAMINE MALEATE TABLET N Pharmacy PA N  
clemastine fumarate CLEMASTINE FUMARATE SYRUP N Pharmacy PA N  
clemastine fumarate CLEMSZA TABLET N Pharmacy PA N  
clemastine fumarate CLEMASTINE FUMARATE TABLET N Pharmacy PA N  
dexbrompheniramine maleate ALA-HIST IR TABLET N Pharmacy PA N  
dexchlorpheniramine maleate CORPHENA SOLUTION N Pharmacy PA N  
dexchlorpheniramine maleate RYCLORA SOLUTION N Pharmacy PA N  
diphenhydramine HCl DIPHENHYDRAMINE HCL ELIXIR N Pharmacy PA N  
hydroxyzine HCl HYDROXYZINE HCL SOLUTION N Pharmacy PA N  
pyrilamine maleate PEDIACLEAR-8 LIQUID N Pharmacy PA N  
triprolidine HCl HISTEX PD DROPS N Pharmacy PA N  
triprolidine HCl TRIPROLIDINE HCL DROPS N Pharmacy PA N  
triprolidine HCl PEDIACLEAR PD DROPS N Pharmacy PA N  
triprolidine HCl HISTEX TAB CHEW N Pharmacy PA N  
chlorpheniramine maleate ED CHLORPED JR SYRUP   N  
chlorpheniramine maleate CHLO-AMINE TAB CHEW   N  
cyproheptadine HCl CYPROHEPTADINE HCL SYRUP   N  
dexchlorpheniramine maleate DEXCHLORPHENIRAMINE MALEATE TABLET ER   N  
diphenhydramine HCl ANTITUSSIVE COUGH SYRUP SYRUP   N  
diphenhydramine HCl HYDRAMINE SYRUP   N  
diphenhydramine HCl CHILDREN'S ALLERGY RELIEF TAB CHEW   N  
diphenhydramine HCl ALLERGY RELIEF TABLET   N  
diphenhydramine HCl DIPHENHYDRAMINE HCL TABLET   N  
diphenhydramine HCl BANOPHEN TABLET   N  
diphenhydramine HCl ALLER-G-TIME TABLET   N  
diphenhydramine HCl ALLERGY TABLET   N  
triprolidine HCl HISTEX LIQUID   N  
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