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 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
ALCAFTADINE LASTACAFT DROPS N PA Document  
DIPHENHYDRAMINE HCL VANAMINE PD DROPS N PA Document  
HYDROXYZINE HCL HYDROXYZINE HCL SOLUTION N PA Document  
TRIPROLIDINE HCL VANACLEAR PD DROPS N PA Document  
AZELASTINE HCL AZELASTINE HCL DROPS    
BEPOTASTINE BESILATE BEPREVE DROPS    
CARBINOXAMINE MALEATE CARBINOXAMINE MALEATE LIQUID    
CARBINOXAMINE MALEATE KARBINAL ER SUS ER 12H    
CARBINOXAMINE MALEATE RYVENT TABLET    
CARBINOXAMINE MALEATE CARBINOXAMINE MALEATE TABLET    
CHLORCYCLIZINE HCL AHIST TABLET    
CHLORPHENIRAMINE MALEATE ED CHLORPED DROPS    
CHLORPHENIRAMINE MALEATE ED CHLORPED JR SYRUP    
CHLORPHENIRAMINE MALEATE CHLORPHENIRAMINE MALEATE TABLET    
CHLORPHENIRAMINE MALEATE ALLERGY-TIME TABLET    
CHLORPHENIRAMINE MALEATE ALLERGY 4-HOUR TABLET    
CHLORPHENIRAMINE MALEATE ALLER-CHLOR TABLET    
CHLORPHENIRAMINE MALEATE ALLERGY RELIEF TABLET    
CHLORPHENIRAMINE MALEATE ALLERGY TABLET    
CHLORPHENIRAMINE MALEATE CHLORPHENIRAMINE MALEATE TABLET ER    
CHLORPHENIRAMINE MALEATE CHLORPHEN SR TABLET ER    
CLEMASTINE FUMARATE ALLERGY RELIEF TABLET    
CLEMASTINE FUMARATE DAYHIST ALLERGY TABLET    
CLEMASTINE FUMARATE CLEMASTINE FUMARATE TABLET    
CYPROHEPTADINE HCL CYPROHEPTADINE HCL SYRUP    
CYPROHEPTADINE HCL CYPROHEPTADINE HCL TABLET    
DEXBROMPHENIRAMINE MALEATE PEDIAVENT LIQUID    
DEXBROMPHENIRAMINE MALEATE ALA-HIST IR TABLET    
DIPHENHYDRAMINE HCL PHARBEDRYL CAPSULE    
DIPHENHYDRAMINE HCL COMPLETE ALLERGY CAPSULE    
DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL CAPSULE    
DIPHENHYDRAMINE HCL DIPHENHIST CAPSULE    
DIPHENHYDRAMINE HCL DIPHEDRYL CAPSULE    
DIPHENHYDRAMINE HCL BANOPHEN CAPSULE    
DIPHENHYDRAMINE HCL ALLERGY RELIEF CAPSULE    
DIPHENHYDRAMINE HCL ALLERGY MEDICINE CAPSULE    
DIPHENHYDRAMINE HCL ALLERGY CAPSULE    
DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL ELIXIR    
DIPHENHYDRAMINE HCL SILADRYL LIQUID    
DIPHENHYDRAMINE HCL DIPHENHIST LIQUID    
DIPHENHYDRAMINE HCL DIPHEDRYL LIQUID    
DIPHENHYDRAMINE HCL COMPLETE ALLERGY LIQUID    
DIPHENHYDRAMINE HCL CHILDREN'S ALLERGY LIQUID    
DIPHENHYDRAMINE HCL BANOPHEN LIQUID    
DIPHENHYDRAMINE HCL ALLERGY RELIEF LIQUID    
DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL SYRINGE    
DIPHENHYDRAMINE HCL SILPHEN SYRUP    
DIPHENHYDRAMINE HCL DIPHEDRYL TABLET    
DIPHENHYDRAMINE HCL DIPHENHIST TABLET    
DIPHENHYDRAMINE HCL BANOPHEN TABLET    
DIPHENHYDRAMINE HCL ALLERGY RELIEF TABLET    
DIPHENHYDRAMINE HCL ALLERGY MEDICINE TABLET    
DIPHENHYDRAMINE HCL ALLERGY TABLET    
DIPHENHYDRAMINE HCL ALLER-G-TIME TABLET    
DIPHENHYDRAMINE HCL DIPHENHYDRAMINE HCL VIAL    
EMEDASTINE DIFUMARATE EMADINE DROPS    
EPINASTINE HCL ELESTAT DROPS    
EPINASTINE HCL EPINASTINE HCL DROPS    
HYDROXYZINE HCL HYDROXYZINE HCL SOLUTION    
HYDROXYZINE HCL HYDROXYZINE HCL TABLET    
HYDROXYZINE PAMOATE VISTARIL CAPSULE    
HYDROXYZINE PAMOATE HYDROXYZINE PAMOATE CAPSULE    
KETOTIFEN FUMARATE KETOTIFEN FUMARATE DROPS    
KETOTIFEN FUMARATE ZADITOR DROPS    
KETOTIFEN FUMARATE EYE ITCH RELIEF DROPS    
KETOTIFEN FUMARATE CHILDREN'S ALAWAY DROPS    
KETOTIFEN FUMARATE ALAWAY DROPS    
OLOPATADINE HCL PAZEO DROPS    
OLOPATADINE HCL PATANOL DROPS    
OLOPATADINE HCL PATADAY DROPS    
OLOPATADINE HCL OLOPATADINE HCL DROPS    
TRIPROLIDINE HCL HISTEX PD DROPS    
TRIPROLIDINE HCL VANAHIST PD DROPS    
TRIPROLIDINE HCL TRIPROLIDINE HCL DROPS    
TRIPROLIDINE HCL M-HIST PD DROPS    
TRIPROLIDINE HCL HISTEX LIQUID