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