Antihistamines, First Generation

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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
triprolidine HCl HISTEX PDX DROPS N Pharmacy PA N  
triprolidine HCl HISTEX PD DROPS N Pharmacy PA N  
triprolidine HCl HISTEX TAB CHEW N Pharmacy PA N  
carbinoxamine maleate CARBZAH LIQUID   N  
carbinoxamine maleate CARBINOXAMINE PD LIQUID   N  
carbinoxamine maleate CARBINOXAMINE MALEATE LIQUID   N  
carbinoxamine maleate CARBINOXAMINE LIQUID   N  
carbinoxamine maleate KARBINAL ER SUS ER 12H   N  
carbinoxamine maleate CARBINOXAMINE MALEATE ER SUS ER 12H   N  
carbinoxamine maleate RYVENT TABLET   N  
carbinoxamine maleate CARBINOXAMINE MALEATE TABLET   N  
chlorpheniramine maleate ED CHLORPED JR SYRUP   N  
chlorpheniramine maleate CHLO-AMINE TAB CHEW   N  
chlorpheniramine maleate ALLERGY-TIME TABLET   N  
chlorpheniramine maleate ALLERGY RELIEF TABLET   N  
chlorpheniramine maleate ALLERGY TABLET   N  
chlorpheniramine maleate ALLER-CHLOR TABLET   N  
clemastine fumarate CLEMASTINE FUMARATE SYRUP   N  
clemastine fumarate CLEMSZA TABLET   N  
clemastine fumarate CLEMASTINE FUMARATE TABLET   N  
cyproheptadine HCl CYPROHEPTADINE HCL SYRUP   N  
cyproheptadine HCl CYPROHEPTADINE HCL TABLET   N  
dexbrompheniramine maleate ALA-HIST IR TABLET   N  
dexchlorpheniramine maleate RYCLORA SOLUTION   N  
dexchlorpheniramine maleate DEXCHLORPHENIRAMINE MALEATE TABLET ER   N  
diphenhydramine HCl ALLERGY CAPSULE   N  
diphenhydramine HCl BANOPHEN CAPSULE   N  
diphenhydramine HCl ALLERGY RELIEF CAPSULE   N  
diphenhydramine HCl DIPHENHYDRAMINE HCL CAPSULE   N  
diphenhydramine HCl DIPHENHYDRAMINE HCL ELIXIR   N  
diphenhydramine HCl SILADRYL DAS LIQUID   N  
diphenhydramine HCl DIPHENHYDRAMINE HCL LIQUID   N  
diphenhydramine HCl DIPHEDRYL LIQUID   N  
diphenhydramine HCl CHILDREN'S ALLERGY RELIEF LIQUID   N  
diphenhydramine HCl CHILDREN'S ALLERGY LIQUID   N  
diphenhydramine HCl ALLERGY RELIEF LIQUID   N  
diphenhydramine HCl M-DRYL LIQUID   N  
diphenhydramine HCl HYDRAMINE SYRUP   N  
diphenhydramine HCl ANTITUSSIVE COUGH SYRUP SYRUP   N  
diphenhydramine HCl CHILDREN'S ALLERGY RELIEF TAB CHEW   N  
diphenhydramine HCl ALLERGY TABLET   N  
diphenhydramine HCl DIPHENHYDRAMINE HCL TABLET   N  
diphenhydramine HCl ALLER-G-TIME TABLET   N  
diphenhydramine HCl BANOPHEN TABLET   N  
diphenhydramine HCl ALLERGY RELIEF TABLET   N  
hydroxyzine HCl HYDROXYZINE HCL SOLUTION   N  
hydroxyzine HCl HYDROXYZINE HCL TABLET   N  
hydroxyzine pamoate VISTARIL CAPSULE   N  
hydroxyzine pamoate HYDROXYZINE PAMOATE CAPSULE   N  
pyrilamine maleate PEDIACLEAR-8 LIQUID   N  
triprolidine HCl TRIPROLIDINE HCL DROPS   N  
triprolidine HCl HISTEX PD DROPS   N  
triprolidine HCl PEDIACLEAR PD DROPS   N  
triprolidine HCl HISTEX LIQUID   N  
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