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 WAL-ZYR TABLET Y    
CETIRIZINE HCL ALLERGY TABLET Y    
CETIRIZINE HCL ALL DAY ALLERGY TABLET Y    
CETIRIZINE HCL 24HOUR ALLERGY TABLET Y    
CETIRIZINE HCL ALL DAY ALLERGY TABLET Y    
CETIRIZINE HCL ALL DAY ALLERGY RELIEF TABLET Y    
CETIRIZINE HCL ALLERGY TABLET Y    
CETIRIZINE HCL ALLERGY RELIEF TABLET Y    
CETIRIZINE HCL CETIRIZINE HCL TABLET Y    
CETIRIZINE HCL ZYRTEC TABLET Y    
CETIRIZINE HCL ALLER-TEC TABLET Y    
CETIRIZINE HCL CETIRIZINE HCL TABLET Y    
LORATADINE ALLERGY RELIEF SOLUTION Y    
LORATADINE CHILDREN'S ALLERGY 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 LORATADINE HIVES RELIEF SOLUTION Y    
LORATADINE LORATADINE ALLERGY SOLUTION Y    
LORATADINE LORATADINE SOLUTION Y    
LORATADINE CHILDREN'S LORATADINE SOLUTION Y    
LORATADINE CHILDREN'S ALLERGY SOLUTION Y    
LORATADINE ALLERGY RELIEF SOLUTION Y    
LORATADINE WAL-ITIN SOLUTION Y    
LORATADINE LORATADINE SOLUTION Y    
LORATADINE CLARITIN TAB RAPDIS Y    
LORATADINE ALAVERT TAB RAPDIS Y    
LORATADINE ALLERGY RELIEF TAB RAPDIS Y    
LORATADINE ALLERGY RELIEF TAB RAPDIS Y    
LORATADINE WAL-ITIN TAB RAPDIS Y    
LORATADINE LORATADINE TAB RAPDIS Y    
LORATADINE ALLERCLEAR TABLET Y    
LORATADINE ALLERGY RELIEF TABLET Y    
LORATADINE NON-DROWSY ALLERGY TABLET Y    
LORATADINE LORATADINE TABLET Y    
LORATADINE ALLERGY RELIEF TABLET Y    
LORATADINE ALLERGY TABLET Y    
LORATADINE WAL-ITIN TABLET Y    
LORATADINE CLARITIN TABLET Y    
LORATADINE LORATADINE TABLET Y    
LORATADINE LORADAMED TABLET Y    
CETIRIZINE HCL CHILDREN'S ALL DAY ALLERGY SOLUTION N PA Document  
CETIRIZINE HCL CHILDREN'S CETIRIZINE HCL SOLUTION N PA Document  
CETIRIZINE HCL CETIRIZINE HCL TAB CHEW N PA Document  
CETIRIZINE HCL ALL DAY ALLERGY 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 ORAL SUSP N PA Document  
FEXOFENADINE HCL FEXOFENADINE HCL TABLET N PA Document  
FEXOFENADINE HCL ALLERGY RELIEF TABLET N PA Document  
FEXOFENADINE HCL ALLER-EASE 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