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.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
alcaftadine LASTACAFT ONCE DAILY RELIEF DROPS N PA Document  
alcaftadine LASTACAFT DROPS N PA Document  
triprolidine HCl HISTEX PDX DROPS N PA Document  
triprolidine HCl HISTEX TAB CHEW N PA Document  
azelastine HCl AZELASTINE HCL DROPS    
bepotastine besilate BEPOTASTINE BESILATE DROPS    
bepotastine besilate BEPREVE 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    
chlorcyclizine HCl AHIST TABLET    
chlorpheniramine maleate ED CHLORPED JR SYRUP    
chlorpheniramine maleate CHLO-AMINE TAB CHEW    
chlorpheniramine maleate ALLER-CHLOR TABLET    
chlorpheniramine maleate ALLERGY TABLET    
chlorpheniramine maleate ALLERGY-TIME TABLET    
chlorpheniramine maleate ALLERGY RELIEF TABLET    
clemastine fumarate CLEMASTINE FUMARATE SYRUP    
clemastine fumarate CLEMASTINE FUMARATE TABLET    
cyproheptadine HCl CYPROHEPTADINE HCL SYRUP    
cyproheptadine HCl CYPROHEPTADINE HCL TABLET    
dexbrompheniramine maleate PEDIAVENT TAB CHEW    
dexbrompheniramine maleate ALA-HIST IR TABLET    
dexchlorpheniramine maleate RYCLORA SOLUTION    
dexchlorpheniramine maleate DEXCHLORPHENIRAMINE MALEATE TABLET ER    
diphenhydramine HCl DIPHENHYDRAMINE HCL CAPSULE    
diphenhydramine HCl COMPLETE ALLERGY CAPSULE    
diphenhydramine HCl BANOPHEN CAPSULE    
diphenhydramine HCl DIPHENHIST CAPSULE    
diphenhydramine HCl ALLERGY CAPSULE    
diphenhydramine HCl ALLERGY RELIEF CAPSULE    
diphenhydramine HCl DIPHENHYDRAMINE HCL ELIXIR    
diphenhydramine HCl SILADRYL LIQUID    
diphenhydramine HCl M-DRYL LIQUID    
diphenhydramine HCl DIPHENHYDRAMINE HCL LIQUID    
diphenhydramine HCl DIPHEDRYL LIQUID    
diphenhydramine HCl CHILDREN'S DIPHENHYDRAMINE LIQUID    
diphenhydramine HCl CHILDREN'S ALLERGY RELIEF LIQUID    
diphenhydramine HCl CHILDREN'S ALLERGY LIQUID    
diphenhydramine HCl SILADRYL DAS LIQUID    
diphenhydramine HCl ALLERGY RELIEF LIQUID    
diphenhydramine HCl ALLERGY LIQUID    
diphenhydramine HCl DIPHENHYDRAMINE HCL SYRINGE    
diphenhydramine HCl HYDRAMINE SYRUP    
diphenhydramine HCl ANTITUSSIVE COUGH SYRUP SYRUP    
diphenhydramine HCl CHILDREN'S ALLERGY RELIEF TAB CHEW    
diphenhydramine HCl ALLERGY RELIEF TAB CHEW    
diphenhydramine HCl DIPHENHYDRAMINE HCL TABLET    
diphenhydramine HCl BANOPHEN TABLET    
diphenhydramine HCl ALLERGY RELIEF TABLET    
diphenhydramine HCl ALLER-G-TIME TABLET    
diphenhydramine HCl ALLERGY 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 ZADITOR DROPS    
ketotifen fumarate KETOTIFEN FUMARATE DROPS    
ketotifen fumarate CHILDREN'S ALAWAY DROPS    
ketotifen fumarate ALAWAY DROPS    
olopatadine HCl EYE ALLERGY ITCH-REDNESS RLF DROPS    
olopatadine HCl OLOPATADINE HCL DROPS    
olopatadine HCl PATADAY ONCE DAILY RELIEF DROPS    
olopatadine HCl PATADAY TWICE DAILY RELIEF DROPS    
olopatadine HCl EYE ALLERGY ITCH RELIEF DROPS    
pyrilamine maleate PEDIACLEAR-8 LIQUID    
triprolidine HCl PEDIACLEAR PD DROPS    
triprolidine HCl TRIPROLIDINE HCL DROPS    
triprolidine HCl HISTEX PD DROPS    
triprolidine HCl HISTEX LIQUID