Antihistamines, First Generation
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 | New Drug Evaluation |
|---|---|---|---|---|---|
| alcaftadine | LASTACAFT ONCE DAILY RELIEF | DROPS | N | PA Document | |
| triprolidine HCl | HISTEX PDX | DROPS | N | PA Document | |
| triprolidine HCl | HISTEX PD | DROPS | N | PA Document | |
| triprolidine HCl | HISTEX | TAB CHEW | N | PA Document | |
| azelastine HCl | AZELASTINE HCL | DROPS | |||
| bepotastine besilate | BEPREVE | DROPS | |||
| bepotastine besilate | BEPOTASTINE BESILATE | DROPS | |||
| brompheniramine maleate | CODIMAL-A | VIAL | |||
| carbinoxamine maleate | CARBINOXAMINE PD | LIQUID | |||
| carbinoxamine maleate | CARBINOXAMINE MALEATE | LIQUID | |||
| carbinoxamine maleate | CARBINOXAMINE | LIQUID | |||
| carbinoxamine maleate | KARBINAL ER | SUS ER 12H | |||
| carbinoxamine maleate | RYVENT | TABLET | |||
| carbinoxamine maleate | CARBINOXAMINE MALEATE | TABLET | |||
| cetirizine HCl | ZERVIATE | DROPERETTE | |||
| chlorpheniramine maleate | ED CHLORPED JR | SYRUP | |||
| chlorpheniramine maleate | CHLO-AMINE | TAB CHEW | |||
| chlorpheniramine maleate | ALLERGY-TIME | TABLET | |||
| chlorpheniramine maleate | ALLERGY RELIEF | TABLET | |||
| chlorpheniramine maleate | ALLERGY | TABLET | |||
| chlorpheniramine maleate | ALLER-CHLOR | TABLET | |||
| clemastine fumarate | CLEMASTINE FUMARATE | SYRUP | |||
| clemastine fumarate | CLEMASTINE FUMARATE | TABLET | |||
| cyproheptadine HCl | CYPROHEPTADINE HCL | SYRUP | |||
| cyproheptadine HCl | CYPROHEPTADINE HCL | TABLET | |||
| dexbrompheniramine maleate | ALA-HIST IR | TABLET | |||
| dexchlorpheniramine maleate | RYCLORA | SOLUTION | |||
| dexchlorpheniramine maleate | DEXCHLORPHENIRAMINE MALEATE | TABLET ER | |||
| diphenhydramine HCl | ALLERGY RELIEF | CAPSULE | |||
| diphenhydramine HCl | ALLERGY | CAPSULE | |||
| diphenhydramine HCl | DIPHENHYDRAMINE HCL | CAPSULE | |||
| diphenhydramine HCl | BANOPHEN | CAPSULE | |||
| diphenhydramine HCl | DIPHENHIST | CAPSULE | |||
| diphenhydramine HCl | DIPHENHYDRAMINE HCL | ELIXIR | |||
| diphenhydramine HCl | SILADRYL DAS | LIQUID | |||
| diphenhydramine HCl | SILADRYL | LIQUID | |||
| diphenhydramine HCl | M-DRYL | LIQUID | |||
| diphenhydramine HCl | ALLERGY RELIEF | LIQUID | |||
| diphenhydramine HCl | DIPHENHYDRAMINE HCL | LIQUID | |||
| diphenhydramine HCl | CHILDREN'S ALLERGY | LIQUID | |||
| diphenhydramine HCl | CHILDREN'S ALLERGY RELIEF | LIQUID | |||
| diphenhydramine HCl | DIPHEDRYL | LIQUID | |||
| diphenhydramine HCl | DIPHENHYDRAMINE HCL | SYRINGE | |||
| diphenhydramine HCl | HYDRAMINE | SYRUP | |||
| diphenhydramine HCl | ANTITUSSIVE COUGH SYRUP | SYRUP | |||
| diphenhydramine HCl | ALLERGY RELIEF | TAB CHEW | |||
| diphenhydramine HCl | CHILDREN'S ALLERGY RELIEF | TAB CHEW | |||
| diphenhydramine HCl | ALLER-G-TIME | TABLET | |||
| diphenhydramine HCl | DIPHENHYDRAMINE HCL | TABLET | |||
| diphenhydramine HCl | ALLERGY | TABLET | |||
| diphenhydramine HCl | ALLERGY RELIEF | TABLET | |||
| diphenhydramine HCl | BANOPHEN | TABLET | |||
| diphenhydramine HCl | DIPHENHYDRAMINE HCL | VIAL | |||
| epinastine HCl | EPINASTINE HCL | DROPS | |||
| hydroxyzine HCl | HYDROXYZINE HCL | SOLUTION | |||
| hydroxyzine HCl | HYDROXYZINE HCL | TABLET | |||
| hydroxyzine HCl | HYDROXYZINE HCL | VIAL | |||
| hydroxyzine pamoate | VISTARIL | CAPSULE | |||
| hydroxyzine pamoate | HYDROXYZINE PAMOATE | CAPSULE | |||
| ketotifen fumarate | EYE ITCH RELIEF | DROPS | |||
| ketotifen fumarate | ALAWAY | DROPS | |||
| ketotifen fumarate | ZADITOR | DROPS | |||
| ketotifen fumarate | KETOTIFEN FUMARATE | DROPS | |||
| ketotifen fumarate | CHILDREN'S ALAWAY | DROPS | |||
| olopatadine HCl | PATADAY ONCE DAILY RELIEF | DROPS | |||
| olopatadine HCl | PATADAY TWICE DAILY RELIEF | DROPS | |||
| olopatadine HCl | OLOPATADINE HCL | DROPS | |||
| olopatadine HCl | EYE ALLERGY ITCH-REDNESS RLF | DROPS | |||
| olopatadine HCl | EYE ALLERGY ITCH RELIEF | DROPS | |||
| pyrilamine maleate | PEDIACLEAR-8 | LIQUID | |||
| triprolidine HCl | TRIPROLIDINE HCL | DROPS | |||
| triprolidine HCl | PEDIACLEAR PD | DROPS | |||
| triprolidine HCl | HISTEX PD | DROPS | |||
| triprolidine HCl | HISTEX | LIQUID |