Antihistamines, Second 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 but eligible patients will encounter a co-pay at the pharmacy.
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
cetirizine HCl CETIRIZINE HCL SOLUTION Y 1 mg/mL Require PA  
cetirizine HCl CETIRIZINE HCL TABLET Y    
cetirizine HCl ALL DAY ALLERGY TABLET Y    
cetirizine HCl ALLERGY TABLET Y    
cetirizine HCl ALLER-TEC TABLET Y    
cetirizine HCl ALL DAY ALLERGY TABLET Y    
cetirizine HCl ALL DAY ALLERGY RELIEF TABLET Y    
cetirizine HCl ALLERGY RELIEF TABLET Y    
cetirizine HCl CETIRIZINE HCL TABLET Y    
cetirizine HCl 24HOUR ALLERGY TABLET Y    
cetirizine HCl WAL-ZYR TABLET Y    
cetirizine HCl ALLERGY TABLET Y    
cetirizine HCl ZYRTEC TABLET Y    
loratadine ALLERGY RELIEF SOLUTION Y    
loratadine CHILDREN'S ALLERGY SOLUTION Y    
loratadine LORATADINE SOLUTION Y    
loratadine LORATADINE ALLERGY SOLUTION Y    
loratadine LORATADINE HIVES RELIEF SOLUTION Y    
loratadine CHILDREN'S LORATADINE SOLUTION Y    
loratadine CHILDREN'S ALLERGY RELIEF SOLUTION Y    
loratadine CHILDREN'S CLARITIN SOLUTION Y    
loratadine CHILDREN'S LORATADINE SOLUTION Y    
loratadine CLARITIN SOLUTION Y    
loratadine CHILDREN'S ALLERGY SOLUTION Y    
loratadine WAL-ITIN SOLUTION Y    
loratadine LORATADINE SOLUTION Y    
loratadine ALLERGY RELIEF SOLUTION Y    
loratadine ALLERGY RELIEF TAB RAPDIS Y    
loratadine CLARITIN TAB RAPDIS Y    
loratadine WAL-ITIN TAB RAPDIS Y    
loratadine WAL-ITIN ALLER-MELTS TAB RAPDIS Y    
loratadine WAL-VERT TAB RAPDIS Y    
loratadine LORATADINE TAB RAPDIS Y    
loratadine ALLERGY RELIEF TAB RAPDIS Y    
loratadine ALAVERT TAB RAPDIS Y    
loratadine ALLERGY TABLET Y    
loratadine ALLERGY RELIEF TABLET Y    
loratadine LORATADINE TABLET Y    
loratadine NON-DROWSY ALLERGY TABLET Y    
loratadine CLARITIN TABLET Y    
loratadine TAVIST ND TABLET Y    
loratadine LORADAMED TABLET Y    
loratadine LORATADINE TABLET Y    
loratadine NUPRIN ALLERGY RELIEF TABLET Y    
loratadine WAL-ITIN TABLET Y    
loratadine VICKS QLEARQUIL ALLERGY TABLET Y    
loratadine ALLERGY RELIEF TABLET Y    
loratadine ALLERGY TABLET Y    
loratadine ALLERCLEAR 10MG TABLET Y    
loratadine ALLERCLEAR TABLET Y    
loratadine ALAVERT TABLET Y    
cetirizine HCl CHILDREN'S CETIRIZINE HCL SOLUTION N PA Document  
cetirizine HCl CHILDREN'S ALL DAY ALLERGY SOLUTION N PA Document  
cetirizine HCl CETIRIZINE HCL TAB CHEW N PA Document  
cetirizine HCl CHILDREN'S CETIRIZINE HCL TAB CHEW N PA Document  
desloratadine CLARINEX SYRUP N PA Document  
desloratadine DESLORATADINE TAB RAPDIS N PA Document  
desloratadine DESLORATADINE TABLET N PA Document  
desloratadine CLARINEX TABLET N PA Document  
fexofenadine HCl FEXOFENADINE HCL ORAL SUSP N PA Document  
fexofenadine HCl ALLER-EASE TABLET N PA Document  
fexofenadine HCl ALLERGY RELIEF TABLET N PA Document  
fexofenadine HCl FEXOFENADINE HCL TABLET N PA Document  
fexofenadine HCl MUCINEX ALLERGY TABLET N PA Document  
levocetirizine dihydrochloride LEVOCETIRIZINE DIHYDROCHLORIDE SOLUTION N PA Document  
levocetirizine dihydrochloride LEVOCETIRIZINE DIHYDROCHLORIDE TABLET N PA Document  
loratadine LORATADINE CAPSULE N PA Document