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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|
| 00131100805 | CODIMAL-A | brompheniramine maleate | VIAL | 10 mg/mL | Y | ||
| 76045010210 | DIPHENHYDRAMINE HCL | diphenhydramine HCl | SYRINGE | 50 mg/mL | Y | ||
| 00641037621 | DIPHENHYDRAMINE HCL | diphenhydramine HCl | VIAL | 50 mg/mL | Y | ||
| 00641037625 | DIPHENHYDRAMINE HCL | diphenhydramine HCl | VIAL | 50 mg/mL | Y | ||
| 00641628201 | DIPHENHYDRAMINE HCL | diphenhydramine HCl | VIAL | 50 mg/mL | Y | ||
| 00641628225 | DIPHENHYDRAMINE HCL | diphenhydramine HCl | VIAL | 50 mg/mL | Y | ||
| 23155026431 | DIPHENHYDRAMINE HCL | diphenhydramine HCl | VIAL | 50 mg/mL | Y | ||
| 23155026441 | DIPHENHYDRAMINE HCL | diphenhydramine HCl | VIAL | 50 mg/mL | Y | ||
| 25021048101 | DIPHENHYDRAMINE HCL | diphenhydramine HCl | VIAL | 50 mg/mL | Y | ||
| 63323066400 | DIPHENHYDRAMINE HCL | diphenhydramine HCl | VIAL | 50 mg/mL | Y | ||
| 63323066401 | DIPHENHYDRAMINE HCL | diphenhydramine HCl | VIAL | 50 mg/mL | Y | ||
| 63323066416 | DIPHENHYDRAMINE HCL | diphenhydramine HCl | VIAL | 50 mg/mL | Y | ||
| 63323066441 | DIPHENHYDRAMINE HCL | diphenhydramine HCl | VIAL | 50 mg/mL | Y | ||
| 67457012410 | DIPHENHYDRAMINE HCL | diphenhydramine HCl | VIAL | 50 mg/mL | Y | ||
| 72485010101 | DIPHENHYDRAMINE HCL | diphenhydramine HCl | VIAL | 50 mg/mL | Y | ||
| 72485010105 | DIPHENHYDRAMINE HCL | diphenhydramine HCl | VIAL | 50 mg/mL | Y | ||
| 72485010125 | DIPHENHYDRAMINE HCL | diphenhydramine HCl | VIAL | 50 mg/mL | Y | ||
| 00517420101 | HYDROXYZINE HCL | hydroxyzine HCl | VIAL | 25 mg/mL | Y | ||
| 00517420125 | HYDROXYZINE HCL | hydroxyzine HCl | VIAL | 25 mg/mL | Y | ||
| 00517560101 | HYDROXYZINE HCL | hydroxyzine HCl | VIAL | 50 mg/mL | Y | ||
| 00517560125 | HYDROXYZINE HCL | hydroxyzine HCl | VIAL | 50 mg/mL | Y | ||
| 00517560201 | HYDROXYZINE HCL | hydroxyzine HCl | VIAL | 50 mg/mL | Y | ||
| 00517560225 | HYDROXYZINE HCL | hydroxyzine HCl | VIAL | 50 mg/mL | Y |